In a discreet corner of a cafe in Chester, Dr Stephen Brearey recalls the exact moment he first connected Lucy Letby to a series of unusual baby deaths on the neonatal unit where they worked.
It was in a meeting with the hospital’s head of nursing and two other colleagues on Thursday, 2 July 2015. “It can’t be Lucy. Not nice Lucy,” he told them.
More than eight years later, 33-year-old “nice Lucy” faces the rest of her life in prison after being found guilty of murdering seven babies and attempting to kill another six in crimes without parallel in modern Britain.
Through exclusive interviews, the uncovering of internal confidential documents, and months of reporting from Manchester crown court, the Observer can today tell the full story of how concerns were raised about Letby for months before she was eventually removed from frontline care in July 2016.
The failure of hospital executives to take urgent action cost the lives of at least two babies – two triplet brothers, murdered within 24 hours of each other – and prolonged Letby’s attacks on other newborns at the Countess of Chester hospital in north-west England, senior doctors believe.
The decisions of executives will now be investigated as part of a non-statutory public inquiry that will scrutinise what they knew and when and, crucially, why no investigation was ordered into the mounting death toll until July 2016 – more than a year after Letby’s presence at a series of unexplained deaths was known. It will also examine why it took almost another year before executives spoke to the police.
Following Letby’s conviction on Friday, the Observer can today reveal that detectives have begun contacting more families whose children they believe may have been harmed by the nurse. The investigation is examining the records of more than 4,000 babies born at the Countess of Chester hospital and Liverpool Women’s hospital in the six years to mid-2016.
One family, whose child was born at the Liverpool hospital when Letby worked there as a trainee, was told by police earlier this year that their case was being investigated as part of the multi-million pound inquiry, Operation Hummingbird. Dozens more potential victims’ families are expected to be contacted in the coming months.
The story of how Letby was finally stopped begins in June 2015. Three newborn babies had died on the neonatal unit in the space of just 14 days. It was a year’s worth of deaths in two weeks.
Brearey, the head consultant paediatrician on the unit, carried out an urgent review. Each of the infants – two boys and a girl, each less than a week old – had been healthy, despite their prematurity. A fourth baby – the twin sister of one of the boys – had almost died after deteriorating suddenly during this two-week period.
There was no obvious cause for the deaths, so Brearey called a meeting with Alison Kelly, the hospital’s head of nursing, and Eirian Powell, the manager of the neonatal unit, on 2 July. There had been only one nurse on duty for each of the four unexplained incidents, the meeting was told. Her name was Lucy Letby.
Letby, then 25, had worked on the neonatal unit for five years by that point. She was well-liked, particularly by Powell and the nurses, and had become an integral part of the team, in part because she was qualified to care for the most unwell babies – those in intensive care – and often volunteered to work extra shifts.
Until April 2016, she lived in staff digs a short walk from the unit, which was handy because she liked to work the night shift, which started at 7.30pm and finished at 8am. It gave her cover for her crimes, as there were fewer staff and parents on the unit overnight. But no one, at this time, was prepared to think the unthinkable.
Letby carried out many of her attacks just moments after the babies’ parents or nurses had stepped out of the nursery. But on one occasion, she was almost caught in the act.
A mother arrived on the neonatal unit at about 9pm with breast milk for her twin boys when she saw Letby standing over one of their incubators. There was fresh blood around his mouth and he was screaming in agony.
When the mother asked Letby what was happening to her days-old son, the nurse tried to assure her that he was fine and said words to the effect of: “Trust me. I’m a nurse”.
By the end of October 2015, five months after Letby was first connected to the unexplained deaths, seven babies had died in unusual circumstances – more than double the mortality rate for an average year.
Letby was found guilty of murdering five of those children. The other two cases were investigated by police, the Observer has been told, but they were not brought to trial.
Another review, in October 2015, again found that Letby was the only staff member present at each of the unexplained deaths. Powell is understood to have raised the mortality rate again with Kelly and another senior manager, but the connection to Letby was felt to be just coincidence, according to Brearey.
Letby, who had by now murdered five babies and attempted to kill another three, was allowed to remain on the unit. But senior doctors, who had been prepared to give the young nurse the benefit of the doubt, were now becoming increasingly concerned.
They asked an independent expert, Dr Nimish Subhedar, to carry out a review of the unusual deaths to find any common themes. He found that the babies had been otherwise stable when they suddenly deteriorated and that all had, unusually, failed to respond to life-saving treatment. Further, their collapses had all happened in the middle of the night. Letby was again noted to be on shift in each case.
Brearey sent the report to the hospital’s medical director, Ian Harvey, in early February 2016 and requested an urgent meeting. Yet despite the rising death toll, no such meeting took place for another three months. This, according to Brearey and other senior doctors, is the point when action should have been taken. Letby’s connection to the deaths was now more than just a coincidence. And no examination so far had found any innocent explanation for them. But yet again, nothing appears to have been done.
In May 2016, by which time Letby had murdered five babies, a hospital manager produced a two-page document responding to the concerns of Brearey and his fellow consultant paediatricians. It was the first time anyone beyond the senior doctors had initiated a formal review of the concerns, despite their gravity. It began: “There is no evidence whatsoever against LL [Lucy Letby] other than coincidence.”
It was not until June 2016 that Letby was removed from the neonatal unit, after murdering two otherwise-healthy triplet brothers within 24 hours of each other. They were her 12th and 13th victims. It was, said Dr John Gibbs, another consultant paediatrician on the unit, the “tipping point” that prompted senior doctors to demand the Hereford-born nurse be taken away from their newborn patients.
But this was a year after an executive first learned of her association with unusual fatalities. By this time, she had murdered seven infants and attempted to kill another six, making her the worst child serial killer in modern British history.
What came next is described by the senior doctors as a Kafkaesque nightmare, in which they felt their concerns were not only dismissed, but they were treated with as much suspicion as Letby. This attitude came from the top down, starting with the hospital’s then-chief executive Tony Chambers, according to Brearey.
“I was talking about all of [the concerns] in one of our meetings with [the executives] in early July [2016] and Chambers’s response was: ‘Well that would be very convenient’,” said Brearey. A second senior doctor corroborated Brearey’s recollection of the meeting, on 4 July 2016. According to the doctors, Chambers was implying that the deaths and unusual collapses were a result of poor care rather than deliberate harm.
“It just astonished me, that attitude, which I think was shared with most of the other execs and probably stemmed from the sort of culture that he gave to the trust as a chief exec,” said Brearey.
Chambers told the Observer that this was a “one-sided account of the meeting where what I said has been taken out of context”. He added: “I also said that there were a significant number of factors to consider, including demand, acuity, clinical care, staffing and environment.”
Despite the concerns about Letby, she was moved to the hospital’s risk and patient safety office. It can now be revealed that she was involved with raising serious incident investigation reports to NHS England – a role that would have given her sensitive access at a time when she was effectively under suspicion of murdering infants.
It is not clear who took the decision to move her to the office, nor how long she was there. But the fact she was moved there at all proves, say the senior doctors, that their concerns about Letby were treated “with contempt”. “It was just unfathomable really. You couldn’t make it up,” said Brearey.
Executives eventually ordered two further reviews in July 2016, yet neither was asked to look specifically at the concerns about Letby. Both concluded that a number of the deaths needed further forensic investigation. Harvey, the medical director, and Chambers, the chief executive, said in a January 2017 meeting with senior doctors that Letby had been proved innocent – and would be returning to the neonatal unit within weeks.
Brearey and his consultant colleagues were stunned. Not only was Letby being allowed to return to the unit, but the senior doctors were ordered to apologise to her for raising the concerns. Two consultants, Brearey and Dr Ravi Jayaram, were told to enter a mediation process with the nurse. Her father, they were told, had threatened to refer them to the General Medical Council unless they withdrew their allegations and welcomed her back.
Faced with the threat of disciplinary action, the doctors sent Letby a carefully worded apology on 28 February 2017. Their letter, which has been seen by the Observer, reads: “Dear Lucy. The increased mortality on the neonatal unit and subsequent reviews and re-designation of the neonatal unit has been very stressful time for all staff and parents. We understand that it has been an exceptionally stressful time for you.
“We would like to apologise for any inappropriate comments that may have been made during this difficult period. As you will be aware, emotions have run high. We are very sorry for the stress and upset that you have experienced in the last year. Please be reassured that patient safety has been our absolute priority during this difficult time.”
Less than three months later, after weeks of anguished meetings about how to prevent Letby from returning to work, Brearey and his colleagues contacted Cheshire police.
It was that meeting, on 27 April 2017, that triggered one of the biggest and most complex murder investigations of recent times in Britain.
Brearey’s colleague Jayaram said he “could have punched the air” when the now-retired detective chief superintendent, Nigel Wenham, listened to the consultants and said that their concerns were “something that [the police] have to be involved with”.
Letby had been just six days from returning to work on the neonatal unit at this point. Instead, she never set foot on the ward again. The next time senior doctors would see her was when her picture appeared on the television news, after her arrest more than a year later, in July 2018.
DS Paul Hughes, who led the investigation, told the Observer the information provided by Brearey and his colleagues had been “the golden thread” for their inquiry. “They have been very brave in coming forward and they’ve put this ahead of their careers, in my view,” he said. “If it wasn’t for their ongoing determination, would there have been more [murders]? I don’t know. It’s difficult to answer or speculate on the future. But they’ve done well.”
If there was a smoking gun in this medically complex case, it was uncovered by one of Letby’s colleagues. On the night before Valentine’s Day in February 2018, nearly a year after police launched their investigation, Brearey was hunched over his computer screen when he spotted something unusual.
He had been asked by detectives to review the care of siblings and twins on the unit and was looking at the records of a seven-day-old boy. The infant, known as Child F, had suffered a serious collapse on the unit in August 2015, a day after his twin brother had died unexpectedly.
In the very last paragraph of Child F’s discharge letter was a line about his insulin level and the level of another hormone called C-peptide. In normal readings, the insulin level would be between 200 and 300. For Child F it was 4,657. The results also showed a very low C-peptide level. It was conclusive proof that he had been poisoned. Letby had laced his feeding bag with insulin a day after fatally injecting air into the bloodstream of his six-day-old twin brother. It was a miracle that Child F had survived.
“I just had this gut-wrenching moment: ‘What the fuck is this?!,’” said Brearey. “It was a smoking gun. You saw it there, in plain sight. If there was any iota of doubt [about her guilt], it was removed then.”
It was, said DCI Nicola Evans, a “real milestone” in the investigation. “We were shocked to the core,” she said.
Letby was arrested five months later, at 6am on 4 July 2018. Her father, John, had stayed the night, and watched as his daughter was led out of her three-bedroom house, where she lived alone with her two cats, Tigger and Smudge, in her nightie and a blue Lee Cooper tracksuit.
Within weeks of her arrest, two of the senior executives involved – Chambers and Harvey – had left the hospital. Kelly, the first to be told of Letby’s connection to unusual deaths, departed soon after. None of the hospital’s leadership was required to give evidence at the 10-month trial at Manchester crown court, yet they will all be expected to cooperate with the inquiry that will follow.
Gibbs, a consultant paediatrician who gave evidence 13 times to Letby’s trial, said the executives must explain why they failed to take action sooner. “Things could have been done differently and probably should have been done differently,” he said.
Gibbs, who has since retired, said he did not know what information hospital leaders had at the time but that more “decisive action” should have been taken in February 2016, five months before Letby was eventually removed, following the murder of the two triplets. “The only people that can tell you that are the managers themselves, so it has to be looked into,” he said.
“Why did the trust manage it the way they did? What information were they getting? And if this sort of concern arose again, in any department in any hospital, how could it be managed differently?”
Letby is expected to become only the third woman in Britain to be given a whole-life prison term, meaning that she will never be released, when she is sentenced on Monday.
She was found guilty of seven charges of murder and seven of attempted murder. The attempted murders relate to six babies, as several charges apply to some of the infants.
She was found not guilty of two charges of attempted murder. The jury was unable to reach verdicts on six further charges of attempted murder, which related to five babies. The Crown Prosecution Service is considering whether to seek a retrial on those charges.
Harvey, the hospital’s former medical director, said he would help the inquiry “in whatever way I can”. He added: “As medical director, I was determined to keep the baby unit safe and support our staff. I wanted the reviews and investigations carried out, so that we could tell the parents what had happened to their children.”
Kelly, the hospital’s former head of nursing, said she too would fully cooperate with the inquiry. She added: “It is impossible to imagine the heartache suffered by the families involved and my thoughts are very much with them. These are truly terrible crimes and I am deeply sorry that this happened to them. We owe it to the babies and their families to learn lessons and I will fully cooperate with the independent inquiry announced.”
Chambers, the former chief executive, said: “All my thoughts are with the children at the heart of this case and their families and loved ones at this incredibly difficult time. I am truly sorry for what all the families have gone through.
“The crimes that have been committed are appalling and I am deeply saddened by what has come to light.
“The trial, and the lengthy police investigation, have shown the complex nature of the issues raised. I will cooperate fully and openly with any post-trial inquiry.”
