Colleagues of neonatal nurse Lucy Letby were ordered to apologise to her after repeatedly raising concerns she may have been behind a series of unexplained baby deaths.
Senior doctors had warned for months that Letby was the only staff member present during the sudden collapses and deaths of a number of premature babies on the neonatal unit of Countess of Chester hospital, in the northwest of England.
She was not removed from the ward until early July 2016, a year after a doctor first alerted a hospital executive to a potential link. By that time, she had murdered seven babies and attempted to kill another six, a court found on Friday.
The Countess of Chester hospital NHS foundation trust is facing serious questions about how it responded to concerns raised about Letby and whether it should have acted sooner.
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Hospital executives ordered a formal review into the spike in deaths in June 2016, a year after the killings began. Letby was removed from the unit the following month and the police were not contacted for almost another year after that.
After the conclusion of the 10-month trial, an investigation by the Guardian based on new documents, interviews with hospital consultants and reporting from the trial, found that, according to two consultant paediatricians in July 2016, a hospital executive said contacting the police would damage the hospital’s reputation and turn the neonatal unit into a crime scene, after one senior doctor recommended bringing in criminal investigators.
The investigation also found that another executive, Tony Chambers, then the hospital’s chief executive, instructed senior doctors to write a letter of apology to Letby on 26 January 2017 for repeatedly raising concerns about her. The apology was ordered on the basis of two external reviews, which executives felt exonerated the nurse.
Neither review, however, was designed to examine whether she, or any other member of staff, was responsible for the deaths and both recommended that several deaths be investigated further.
[ Nurse Lucy Letby guilty of murdering seven babies at Chester hospitalOpens in new window ]
Doctors were told in early 2017 that Letby’s parents had threatened to refer them to the General Medical Council after her removal from the unit, according to internal documents, the investigation found.
Lucy Letby trial: what the jury heard
Presented by Bernice Harrison.
The trial at Manchester crown court heard how Letby was found to have been on duty during three unexplained deaths of babies and a life-threatening collapse over 14 days in June 2015. This was the same number of babies as would die in an average year on the unit.
Alison Kelly, the director of nursing and deputy chief executive of the hospital, was told that Letby was present during all the incidents at this time, the court heard.
Concerns were raised several more times by consultants as babies continued to die unexpectedly. Letby was finally removed from the unit in early July 2016.
The Care Quality Commission (CQC) said consultants told inspectors during a meeting in February 2016 they had raised patient safety concerns with management but felt they were not being listened to.
This meeting took place during a planned inspection of the hospital. The CQC said it had passed these concerns on to Ian Harvey, the hospital’s medical director, later that day.
Senior doctors were ordered to apologise to Letby in January 2017 after the two reviews.
One, by the Royal College of Paediatrics and Child Health, looked at the general operation of the neonatal unit during the period of higher mortality and recommended increasing staffing levels, among other improvements.
It added: “We were not commissioned to conduct detailed case note reviews but, given the circumstances, we recommend that this is initiated immediately, prioritising the deaths that were considered unexpected.”
A second review looked at the medical records of 13 babies who died unexpectedly and four who survived sudden collapses, between June 2015 and June 2016. This report made a series of recommendations but called for a “broader forensic review” of four deaths it said “remain unexpected and unexplained”.
These reviews were considered by executives to clear Letby of any wrongdoing and they decided in January 2017 that she should return to the neonatal unit, documents show.
Bereaved parents were told the following month the reviews had not found any suspicious circumstances in their babies’ deaths.
In a meeting called to discuss these reports on January 26th, 2017, Chambers said he had spent hours talking to Letby and her father and that he believed she was innocent, according to internal documents and interviews with two paediatric consultants, Dr Steve Brearey and Dr John Gibbs.
Chambers then ordered the consultants to apologise to Letby and said she would return to work on the unit imminently. In the event, she did not return to the neonatal unit and a police investigation began four months later.
Gibbs said: “To be told what the reviews showed without having seen them at all was a bit surprising and then to be told we were to draw a line under the matter and that was it, and then to be instructed to send a letter of apology to Lucy Letby was just flabbergasting.”
Gibbs, who gave evidence 13 times at Letby’s trial, said senior doctors had started to “think the unthinkable” in suspecting foul play but that he didn’t “think the management could accept that”.
After Letby’s removal from the unit in July 2016 there were discussions about contacting the police but the hospital decided to carry out two external reviews first.
Brearey said that on one occasion, Stephen Cross, the hospital’s director of corporate affairs and legal services, said contacting the police would be “terrible” for the hospital’s reputation and turn the neonatal unit into a crime scene.
Gibbs said he could not recall Cross’s exact words but that they were “along the lines of ‘The police will come in and everything will be disrupted and the police would treat the NNU [neonatal unit] as a crime scene’”.
“Hearing Stephen Cross say that was really upsetting,” Gibbs said.
In a letter to consultants in May 2018, Chambers said the hospital trust had “always kept an open mind and had under consideration a potential police investigation” but there were “a series of reviews to be undertaken before getting to that point”.
Chambers left the trust within weeks of Letby’s arrest in July 2018.
An external review into the trust’s handling of the spike in deaths was ordered by Chambers’s successor as chief executive, Dr Susan Gilby. The review is understood to have been completed but has not yet been published.
In his May 2018 letter to consultants, Chambers said Harvey, the hospital’s medical director, “accepts communications could have been better” but that Harvey was constrained about how much he could share with the consultant paediatricians due to the two inquiries and later the police investigation.
Chambers added: “Whilst inevitably there are lessons to be learned for us all, I believe the trust can demonstrate that it has taken the concerns that you have raised very seriously and has been open and transparent with the coroner, our regulators, and, as far as the police investigation allows, with staff, parents and the public.”
He said it had been “one of the most intellectually and emotionally challenging sequence of events that I have ever had to manage in my professional career and I am sure I have been found lacking. Without doubt, the need to balance the competing priorities of the safety of babies and their families, the health and wellbeing of our staff and the reputation of our services makes it easy to question my judgment and my approach to managing these.
“I am certain that I have not always got the balance right and inevitably managed to upset everybody including you, nurse X [Letby] and her family and the wider neonatal team; however, it is also important to remember that my stewardship responsibilities include that of the whole hospital and wider healthcare system.”
Chambers and Kelly, now the interim director of nursing at the NHS Salford Care Organisation, said it would not be appropriate to comment during a trial.
After the verdicts, Chambers said: “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 co-operate fully and openly with any post-trial inquiry.”
Harvey said: “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. I believe there should be an inquiry that looks at all events leading up to this trial and I will help it in whatever way I can.”
The trust said it was committed to ensuring lessons were learned. Dr Nigel Scawn, its executive medical director, said: “Since Lucy Letby worked at our hospital, we have made significant changes to our services. I want to provide reassurance that every patient who accesses our services can have confidence in the care they will receive.”
Kelly said: “We owe it to the babies and their families to learn lessons and I will fully co-operate with the independent inquiry announced.”
The Guardian made repeated attempts to contact Cross for comment. – The Guardian