During the two criminal trials of Lucy Letby, jurors were given a huge volume of complex evidence including tens of thousands of pages of medical notes, swipecard data, witness testimony, Facebook messages and more.
Letby, now 34, was found guilty of murdering seven babies and attempting to murder another seven on the neonatal unit of the Countess of Chester hospital in north-west England.
Those convictions are now the subject of intense debate. Some experts have questioned the medical science and other evidence used in the trials. Yet four of Britain’s most senior judges have ruled there are – at present – no grounds for appeal. A fresh legal challenge is being prepared by Letby’s new barrister.
As concerns surrounding the convictions grow, a public inquiry is examining the events surrounding the spike in premature baby deaths at the hospital. It is not, however, engaging with the question of whether the nurse is guilty in the first place.
Over the course of five weeks at Liverpool town hall, the Thirlwall inquiry has uncovered new details about Letby, the neonatal unit on which she worked, and the shocking experiences of the bereaved families at the heart of this scandal.
For some, this new evidence – most of which was not heard during the criminal trials – will help explain how this young university-educated nurse was able, in the words of one detective, to “operate in plain sight”. To others, it may strengthen their belief that these tragic events had a more innocent explanation.
Here is what we have learned so far from the Thirlwall inquiry.
Letby’s character
Jurors who sat through Letby’s original 10-month trial were given only glimpses of her personality when she was in the dock. None of her family, friends or colleagues who had stood by her took to the witness box to give evidence in her defence, so it was Letby herself who had to paint the picture. Her 14 days of testimony left many in court with more questions than answers.
At the Thirlwall inquiry, a fuller – and more complicated – picture has emerged. Some fellow nurses have described their former colleague as “a little strange”, “uncompassionate” and “cold”, while others have said she was well liked and competent.
A number have recalled how she imparted the terrible news of baby deaths – those she was later convicted of murdering – in an “excited” and “gossipy” way. On one occasion, shortly after the sudden and unexpected death of a second triplet in 24 hours, Letby said to a nurse who was just starting her shift: “You will never guess what’s just happened.”
Although some found her behaviour a little odd, Letby seemed a popular member of the unit she had joined in 2012, aged 22. Eirian Powell, the ward manager, described her at the time as “one of my best nurses”, whose “practice was second to none” and “meticulous”, “clever”, “exceptional” and “very professional”.
There were concerns about Letby’s ability, however. The most serious incident came in 2013 when she gave a newborn boy 10 times the dose of morphine he required, a potentially fatal error that was fortunately spotted by a colleague soon after.
Another nurse who was involved in the morphine incident “wanted to resign and was really distressed”, the inquiry has been told. But Letby’s reaction was to be unhappy that she had been temporarily stopped from administering controlled drugs. Asked whether this was a normal response from someone who had made a “potentially catastrophic” error, Yvonne Farmer, the practice development nurse at the time, said: “Maybe not.”
In April 2016, Letby gave antibiotics to a newborn who did not need it. Again, the nurse appeared not to recognise the seriousness of her mistake, writing: “On reflection I feel this situation was unavoidable.”
It has also emerged that Letby failed her final student placement in 2011 due to concerns about her competence – an uncommon result for a trainee nurse on the brink of qualifying. Nicola Lightfoot, the then deputy manager of the children’s unit who failed Letby, told the inquiry she was “concerned about her interaction, how she communicated” and that her clinical knowledge was “not where it should be”.
Another of Letby’s mentors, Sarah Jayne Murphy, said in a written statement that the nurse “did not show good interpersonal skills with parents” and that she and other staff found her “awkward and quiet”.
Letby went on to qualify weeks after being failed by Lightfoot, whom Letby found “intimidating”, and she became a popular member of the unit’s tight-knit nursing team. Her colleagues even planned a tea party to welcome Letby back to the neonatal unit when she was “exonerated” of harming babies by two external reviews in early 2017, the inquiry has heard. Her return never happened, however, as the police were contacted in April that year.
Missed opportunities to involve police
While doctors were trained to spot safeguarding concerns relating to babies’ relatives, there was no similar training in how to respond to potential harm by a fellow staff member. This was despite the legacy of Harold Shipman, Beverley Allitt and, more recently, the insulin poisoner Victorino Chua at a hospital 40 miles from the Countess of Chester. Many have described this as a significant gap in their knowledge.
It has emerged that senior doctors on the neonatal unit were not following NHS protocol for reporting the sudden unexpected death of a child, which should automatically have involved the police and other agencies. Consultant paediatricians on the unit have told the inquiry that they mistakenly believed that the policy – known as the sudden unexpected death in infancy and childhood (Sudic) protocol – applied only to deaths outside a hospital.
It meant the police were not automatically alerted to the unexpected and unexplained deaths of Letby’s victims as early as June 2015, although other inquiries were undertaken.
One consultant, who can be referred to only as Dr ZA, said it was not the “practice and culture” to alert the police to these types of deaths at the time because the Sudic protocol was “very invasive and not necessary, which obviously we now know is not the case”.
Clinicians and managers also missed opportunities to spot similarities between the series of deteriorations of babies because they were not formally reported as serious incidents. Senior doctors have told the inquiry they would have been more alert to the “dramatic” pattern of near fatal incidents if they had completed what is known as a Datix form, a mandatory method of reporting clinical incidents such as deaths, drug errors and equipment failures.
Understaffed
The Countess of Chester neonatal unit averaged one or two deaths a year before 2015, low rates that were comparable to those of similar hospitals in the region. Then, over 14 days in June 2015, three newborn babies died suddenly, each in unusual circumstances. Within 12 months, another four infants had died unexpectedly and several more had had near fatal deteriorations.
Throughout that period, the inquiry has heard, the neonatal unit had a serious shortage of consultants and junior doctors. Executives were warned at a meeting in January 2016 that the hospital’s paediatric service was “almost at breaking point” and needed support “before it hits the point of burnout”, according to minutes of a meeting published by the inquiry.
There were seven consultants spread between the neonatal unit and the children’s ward, with plans to recruit another two. This meant senior doctors would carry out ward rounds only twice a week, compared with daily at other hospitals.
“Lucy could hide what she was doing within people being generally busy,” Dr ZA said. The paediatrician said there was “less time for the non-urgent acute things like reviewing the deaths afterwards and reviewing other incidents because we were so busy just trying to cover the acute service”.
Insulin errors
The most glaring missed opportunity was when doctors failed to realise the significance of a blood test suggesting that a newborn boy, Child F, had been poisoned with insulin in August 2015.
Scientists at a clinical laboratory in Liverpool were asked to analyse a blood sample when Child F’s blood sugars plummeted shortly after birth. The request was not marked as urgent, despite it being an unusual test for a newborn baby, so the sample was frozen and analysed six days later, by which time the child’s condition had markedly improved.
The result alarmed the biochemists in Liverpool as it raised three possibilities: either Child F had been given too much insulin, or he had mistakenly received insulin meant for another child or – the most serious scenario – he had been poisoned by someone.
A scientist in Liverpool quickly telephoned the result to the laboratory at the Countess, who passed it on nine minutes later to a junior doctor on the neonatal unit. The idea of a poisoner on the unit was dismissed as “so fantastical and unlikely” that it could not be right, Dr ZA told the inquiry.
It was a significant mistake, one that the consultant said she “deeply regrets”. They were unable to take another blood sample as Child F had by now improved, so no further action was taken. It was a “collective failure”, said Dr John Gibbs, a now-retired consultant paediatrician.
A jury would later find Letby guilty of having attempted to murder Child F by lacing his feeding tube with insulin and trying to kill another newborn by the same method eight months later.
Ashleigh Hudson, a nurse who joined the neonatal unit in February 2015, said the care of babies “wasn’t as proactive as it should have been” and that there were an “awful lot” of junior doctors who lacked experience in dealing with premature babies. “They would say: we’ll wait until Wednesday for the [consultants’] ward round” instead of making decisions themselves, she said.
Nurses
The staffing issues extended to Letby’s nursing colleagues, whose rota was a fifth below national guidelines, with few qualified to treat the sickest babies.
Gibbs said the shortage of nurses had been a “longstanding problem” on the unit – it had been identified as a risk five years earlier, in 2010 – but that staffing levels were slightly better than on comparable wards in Cheshire and Merseyside.
Powell, the ward manager, told the inquiry they lost two of their most qualified nurses – advanced neonatal practitioners (ANNPs) – some years before the spike in deaths for “financial reasons”. Other NHS trusts regard ANNPs as an “integral part” of neonatal units but the Countess of Chester was without one, even though it was treating a growing number of vulnerable premature babies.
Parents could tell the unit was stretched. “There was a board on the wall that said how many staff should be on duty and how many staff were actually on duty,” said the mother of Child N, a newborn boy whom Letby was convicted of attempting to kill. “The board said five or six should be working, but there were usually three or sometimes four.”
While staffing crises are common in the NHS, the problems at the Countess of Chester were worsened by the fact that junior doctors were refusing to work at the hospital because, unlike others, it had not lifted a cap on the locum fees they could earn.
“If you had a choice of where to work, people weren’t taking up the locum offers at the Countess of Chester,” Dr Huw Mayberry, a junior doctor, told the inquiry. Mayberry said he raised this issue with consultants but executives were “steadfastly” refusing to lift the pay cap. At times, he said, there were only three full-time junior doctors to fill eight roles.
Neonatal unit isolated
Five years before the spike in deaths, the paediatric department was “downgraded” and moved out of the women and children’s directorate and into urgent care. This meant that the neonatal unit was separated from obstetrics, so a mother could be on the labour ward but her baby on the neonatal unit under a completely separate department.
This had numerous knock-on effects, not least that managers in midwifery were not aware of issues on the neonatal unit, despite the two services being interlinked, and senior doctors on Letby’s unit had less of a clear line to management to raise concerns.
“It did concern me that the governance structure and the divisional structure was so separate. I hadn’t seen that anywhere else,” said Dr Paul McGuigan, a consultant paediatrician, who said executives were far removed from the concerns on the unit.
Dr ZA said the neonatal unit was “very much sidelined”, while another consultant, Dr Elizabeth Newby, said: “We were all quite concerned about it at the time because of the obvious link between obstetrics and neonates. Being in two different divisions seemed to make that difficult, really.”
What happens next
The inquiry by Lady Justice Kate Thirlwall will resume on 4 November and two of the most senior clinicians who raised concerns about Letby, Dr Stephen Brearey and Dr Ravi Jayaram, will give evidence over the coming weeks.
The inquiry will then hear testimony from executives including Tony Chambers, the then chief executive of the hospital trust, and Ian Harvey, the former medical director.
The hearings are expected to continue until early 2025, with findings published by late autumn of that year.
