Lucy Letby: Hospital Ignored Warnings and Missed Opportunities to Stop Killer Nurse

Neonatal nurse Lucy Letby has been convicted of murdering seven babies and attempting to murder six more.

Letby committed her crimes at the Countess of Chester Hospital in Chester, where she had worked in the neonatal unit since qualifying in 2011. Prior to that she undertook a student placement in the unit as part of her nursing degree at Chester University.

For all the criminal proceedings against Letby have drawn to a conclusion, there will be a lot more scrutiny of the decisions and processes that allowed her to commit her crimes, unchallenged, for such a lengthy period of time. There will undoubtedly now be a full public inquiry, the outcome of which will be very unflattering for the various agencies involved.

To put not too fine a point on it, there have been serious failings at the Countess of Chester Hospital. Those failings have undoubtedly facilitated the commission of Letby's crimes and have needlessly put the lives of babies in danger. Senior managers have a lot of questions to answer about why they repeatedly ignored concerns about Letby's presence during the attacks and why they refused to report suspicions to the police.

During the trial jurors heard that clinicians on the neonatal unit first raised concerns about Letby after the death of Child D in June 2015.

Dr Stephen Brearey, consultant in charge of the unit, carried out an informal review into the recent increase in the number of deaths. At this point there had been 3 deaths within the space of a month, whereas there would normally be 2 or 3 in a full year. He noted that Letby was present on the unit during the incidents involving Children A-D.

Dr Brearey discussed his observations with Dr Ravi Jayaram, the consultant in charge of the paediatric unit. It would appear that nothing further was done at this point, other than to closely monitor the situation. In his evidence, Dr Jayaram told the court that "all eyes" were on Letby from this point onwards.

Blood tests ordered after the sudden hypoglycemic collapse of Child F on 5th August 2015 should have sounded further alarm bells when they revealed an abnormally high level of synthetic insulin in his blood. Child F had no medical need for insulin and it was not prescribed for him. Furthermore, no other babies on the unit were being prescribed insulin at the time, which ruled out accidental administration. With the benefit of hindsight, the only logical explanation was that Child F had been deliberately poisoned with insulin, although medical staff failed to recognise the significance of the abnormal blood results at the time.

In October 2015, around the time of Child I's death, concerns about Letby were reported to the Countess of Chester's director of nursing, Alison Kelly. Mrs Kelly, who no longer works at the hospital, thought it unlikely that anything of concern was happening, so no formal action was taken.

In February 2016, around the time of the attempted murder of Child K, further concerns were raised about Letby's presence during many of the incidents. Dr Jayaram walked in on Letby just after the collapse of Child K. By this stage Dr Brearey had asked an independent neonatologist, Dr Nim Subhedar, to conduct a review into deaths on the unit. Letby's presence was raised as a "common factor" during a conversation between Drs Brearey and Subhedar. Dr Brearey forwarded the review report to hospital senior managers and demanded an urgent meeting, but his request went ignored. Dr Jayaram said that he and Dr Brearey were under pressure from hospital bosses "not to make a fuss".

In June 2016, as a result of the murders of triplet brothers Children O and P, Dr Brearey decided that he again needed to raise urgent concerns about the presence of Letby during deaths on the unit. As was common practice on the neonatal unit, a debrief was held shortly after the death of the boys. Dr Brearey recalls that unlike her colleagues, Letby did not seem upset or distressed at their deaths. Dr Brearey suggested to Letby that she take a few days off work to recover, but she flatly refused.

Dr Brearey did not want Letby back on the neonatal unit the following day so he called hospital executive Karen Rees to request that Letby be suspended from work pending an investigation into the deaths of Children O and P.

Recalling the conversation, Dr Brearey said: "So, following the staff debrief, I phoned the duty executive on call, Karen Rees, senior nurse in the urgent care division.

"She was familiar with our concerns already. I explained what had happened and I didn't want Nurse Letby to come back to work the following day or until this was all investigated properly. Karen Rees said 'no' to that and that there was no evidence." 

He added: "I put it to her was she happy to take responsibility for this decision in view of the fact that myself and my consultant colleagues all wouldn't be happy with Nurse Letby going to work the following day.

"She responded she was happy to take that responsibility. We had further conversations with executives the following week and action was taken."

The following day, 25th June 2016, Letby attended work as normal and was implicated in the collapse of Child Q. The jury was unable to reach a verdict on the attempted murder of Child Q, although Letby may well have been responsible. Had she been suspended, as requested by Dr Brearey, then Child Q's collapse may never have happened.

As a result of Child Q's collapse, Letby was finally removed from the neonatal unit and assigned to a clerical role in the hospital's risk and patient safety office.

Dr John Gibbs, a consultant on the neonatal unit, told the court: "In the eleven months before the police got involved, after we raised concerns about the triplet's deaths (Children O and P), senior managers were extremely reluctant to involve the police to discuss what was happening.

"We had to keep insisting the police be involved."

The court heard that hospital managers wanted Letby to return to the neonatal unit, where the incidents had now stopped in her absence, but staff on the unit firmly opposed her return.

Dr Gibbs said: "After the deaths of the triplets, because concerns had reached a tipping point, safety measures were introduced.

"One of the key safety measures, which the consultants had been insistent on, was that Lucy Letby was removed from the neonatal unit.

"That was not a simple or straightforward decision.

"A month later senior managers wanted Staff Nurse Letby to come back on the unit and we said that should only happen if CCTV was put in each room on the unit.

"Over the next 11 months we had to resolutely resist repeated attempts by management to have Staff Nurse Letby come back to the unit."

Letby didn't return to the neonatal unit and she was eventually arrested on 3rd July 2018 - more than 3 years, 4 murders and 14 attempted murders after concerns were first raised.

On the face of things, it would seem that the performance of senior managers at the Countess of Chester Hospital has been woefully inadequate. Their lethargy and reluctance to address the concerns of clinical colleagues, has allowed Letby to continue her murderous spree.

Lessons must be learnt, the victims and their families must get answers and individuals must be held to account.