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The Report
Volume I
Part One
Chapter 3

Chapter 3. June 2015: Baby A, Baby B, Baby C and Baby D

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Chapter 2
The neonatal unit, 2015 to 2016
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Chapter 4
Risk and Patient Safety Department

Contents

Baby A

Mother A and B: “2015 was going to [be] the best year of our lives. We were going to become parents … Everything was perfect.”1

  1. On 8 June 2015, just before 9pm, Baby A died in Nursery 1. Baby A was the older of twins and considered the stronger baby.
  2. Baby A and Baby B were delivered at 31 weeks and 2 days’ gestation by caesarean section in the maternity unit of the Countess. Baby A weighed slightly over 1.66 kilograms. Mother A and B remembered being told “that my baby, for a pre-term baby, was in one of the best conditions that they’d ever seen and then hours later, [Baby A] died”.2
  3. Baby A and Baby B were taken to the neonatal unit shortly after birth. Mother A and B, after spending time in recovery, was taken to her room. Father A and B took photographs of the babies so she could see them. Mother A and B was told to rest but was, naturally, desperate to see her babies. She was told that the doctors were trying to get lines into Baby A, so she would have to wait.
  4. Ms Taylor was an experienced neonatal nurse (band 6) who had completed her intensive care training. She was Baby A’s designated nurse for the day shift on 8 June 2015. She told the Inquiry that she had no concerns about Baby A. Baby A had had a period of respiratory support earlier in the day. Baby A was stable throughout the shift, including at handover to Letby, a band 5 nurse, who was Baby A’s designated nurse for the night shift.3
  5. During the course of the day, an umbilical venous catheter (UVC) was put in position for the administration of fluids. An X-ray showed it was not in the right position. It was replaced on the advice of Dr Jayaram, but the correct position was still not achieved. Dr David Harkness, a paediatric registrar, therefore inserted a long line at about 7pm.

Collapse

  1. Nurse T, a neonatal nurse (band 6), was the night shift leader. She arrived on the unit at 19:30 for handover. Shortly after 8pm, she walked through Nursery 1. She noted that Letby was standing at Baby A’s incubator with her back to Ms Taylor, who was writing up her notes.4 Ms Taylor noticed Baby A begin to deteriorate.5 A crash call was put out and Dr Harkness, Dr Jayaram, Dr Rachel Lambie (a paediatric and neonatal registrar) and Dr Christopher Wood (a GP trainee) arrived. Dr Harkness removed the long line, and nurses and the doctors were involved in Baby A’s resuscitation.6 Nurse T explained she had left the unit for a “few minutes” and “in the time I had been off the unit [Baby A] had collapsed, [Baby A] had no heartbeat and needed full resuscitation”.7 In her written statement to the Inquiry, Ms Caroline Bennion, a senior neonatal practitioner (band 6), confirmed her police statement that she had worked in neonatal care for 22 years and had experienced sudden collapses before. She said that Baby A was an exception. Baby A deteriorated within minutes – within half an hour Baby A had deteriorated, then died. She described it as an “absolute shock!”
  2. Ms Taylor described Baby A’s death as “extremely traumatic and difficult”.8 She too described being in shock. In her oral evidence to the Inquiry, she described Baby A’s death as “very unexpected”.9 Nurse T said “it was completely unexpected”,10 adding: “[W]e just didn’t understand how this baby that was so well had collapsed in such a catastrophic way.”11
  3. Mother A and B told the Inquiry that, prior to Baby A’s death, Father A and B heard nurses “say there’s something wrong with Child A, and discussing whether they should come and get me and my partner”.12 She went on to say: “[T]hey came to get me when [Baby A had] already crashed and there was nothing more that could be done.”13
  4. The first time Mother A and B held her child was after Baby A had died. She described feeling “traumatised” and that there was a “gaping hole where Child A should be”.14
  5. Not only was Baby A’s death sudden and unexpected; it was also unexplained. In evidence Nurse T said: “[I]n what’s now 25 years of neonatal nursing experience, I have never witnessed a deterioration in that manner that fast. And we didn’t have any explanation for that.”15

Skin changes

  1. Before Baby A’s death, a number of doctors and nurses had noticed an unusual rash across Baby A’s body. Dr Harkness described the rash as “an unusual blotchy pattern of well perfused pink skin over the whole of Child A’s body, coupled with patches of white and blue skin”. He is also recorded as saying: “In my professional career, this spans over 10 years. I have never witnessed or seen that pattern of discolouration on the skin prior to the collapse.”16
  2. Nurse T said of the skin changes: “I had never seen anything like that previously and I had been doing neonates for over 15 years at that point. And I have never seen anything like it since except on [Baby B].”17
  3. The rash was something that Dr Harkness says he discussed in “multiple conversations following Child A’s death” with registrars, senior house officers and “possibly the consultants”.18 Dr Lambie had been crash called to Baby A and arrived a few minutes into Baby A’s resuscitation. She recalled subsequently speaking to Dr Harkness about the unusual rash that neither of them had seen before.19
  4. Dr Jayaram described the rash: “These patches seemed to appear and disappear. It wasn’t like [a] rash … it would flit and reappear and disappear. It didn’t fit with anything I’d ever seen before.”20 In oral evidence to the Inquiry, Dr Jayaram accepted that he failed to record the unusual discolouration he observed on Baby A in the medical notes. In retrospect, he wished he had.21 Dr Jayaram also failed to refer to the discolouration in his statement to the coroner about Baby A’s death, dated 24 July 2015.22 These were two significant failings by Dr Jayaram, not least because this was something he had never seen before, the junior doctors had also noticed it, were puzzled by it and were raising concerns about it at the time. I accept that he observed the discolouration. Whilst he may not have understood its significance at the time, he should have recorded it. At the end of his note, made at 23:25, Dr Jayaram wrote: “Will need notes, all prescription charts and X rays for PM [post-mortem].” There was no question of anything being held back from the coroner.
  5. Baby A’s parents were not informed about Baby A’s rash. Mother A and B told the Inquiry they did not find out about it until the inquest in October 2016. She heard then that “staff had witnessed blotching/mottling, travelling across Child A’s chest and body. I was not aware of this at the time of Child A’s death.”23
  6. The doctors considered whether placement of the long line or the UVC had contributed to Baby A’s death, and also whether Mother A and B’s blood disorder may have contributed. Dr Murthy Saladi, a consultant paediatrician, completed a coroner’s authorisation form, drawing attention to a number of matters, including the siting of the UVC and of the long line.24 Blood samples were sent to a haematologist at a London teaching hospital where Mother A and B had been treated for some time. The results were discussed with doctors at Great Ormond Street Hospital. There was agreement that Baby A’s death was unrelated to Mother A and B’s blood disorder. Dr Rajeev Shukla, a consultant paediatric pathologist, performed the post-mortem on 10 June 2015. He produced two post-mortem reports. He found that Mother A and B’s blood disorder had not contributed to Baby A’s death. He identified a structural anomaly in the aorta, which he did not consider had any role in Baby A’s death. He also considered the placement of the long line and reviewed the literature, and found that it had not contributed to Baby A’s death. In each report, he concluded that the cause of Baby A’s death was ‘unascertained’.
  7. An inquest was opened on 23 December 2015. The inquest hearing was originally listed to be heard on 23 March 2016 but was adjourned as the evidence had not yet been received. The inquest hearing took place on 10 October 2016 before Mr Nicholas Rheinberg, Senior Coroner for Cheshire, who, having heard evidence, found the cause of death to be ‘unascertained’. I deal with the inquest in detail in Chapter 24.
  8. Letby was convicted of Baby A’s murder.

Baby B

  1. As well as being traumatised by the death of Baby A, Parents A and B were “riddled with fear for … Child B”.25 Baby B weighed just over 1.66 kilograms. On 9/10 June 2015, the night shift following the death of Baby A, Baby B collapsed and required resuscitation. Baby B survived. Letby was convicted of the attempted murder of Baby B.
  2. Baby B was being cared for in Nursery 1. Nurse T was Baby B’s designated nurse. Letby had been allocated two babies in another nursery.

Collapse

  1. At 20:00, Nurse T was satisfied with the observations and Baby B was active. In oral evidence, Nurse T described Baby B’s collapse later that night as “sudden”.26 She said that prior to midnight, Baby B had knocked out the continuous positive airway pressure (CPAP) prongs, which were passing oxygen into the nose. As a result, Baby B’s oxygen saturation dropped and an alarm sounded. The prongs were put back into position by Nurse T, who asked Dr Lambie to have a look at Baby B: “Dr Lambie was on the unit, so we were all satisfied that it had just been because the prongs had come out.”27 Baby B seemed to recover. Shortly afterwards, Baby B’s CPAP machine alerted again, indicating the pressure had been lost and the prongs had come out. Nurse T was drawing up antibiotics and had gloves on, so Letby attended to Baby B. Nurse T recalled Letby saying: “‘Nurse T, come over, [Baby B] looks like [Baby A]’ and I went over and [Baby B] did have that blotchy rash and had collapsed in a similar manner.”28 Nurse T recalled “worrying that we were going to be in a similar situation that we had been in the night before”.29
  2. Dr Lambie received a crash bleep to attend the neonatal unit soon after midnight.30 She attended and assisted in the ventilation of Baby B. She recorded in the medical notes: “Had acute apnoea with no warning. Widespread purple discolouration of skin with white patches.”31 In oral evidence, Dr Lambie vividly described Baby B’s collapse as “so acute and so unusual”.32 She recalled that Baby B was “covered in a very unusual rash” that was moving.33 She considered whether it could be a meningococcal septicaemia, but “that diagnosis didn’t fit in this situation so nothing made sense”.34 As Dr Lambie examined Baby B, a nurse commented: “[T]his is the same thing that happened to Child A yesterday.”35 Dr Lambie successfully intubated Baby B, who improved.
  3. Dr V, the consultant paediatrician on call, was contacted at home shortly after 12.30am. She said in evidence that Baby B’s deterioration was unexpected.36 She arrived on the unit at 00:50, shortly after Dr Lambie had successfully intubated Baby B. Dr V’s clinical notes read: “Upon my arrival purple blotchiness.”37 Later, at 02:40, she noted: “[P]urple discolouration almost resolved – ?? cause – stabilised at present.”38 She confirmed she was puzzled by what had happened, hence the two question marks. She described the rash as “florid and widespread” and “blotchy”.39 At the time, Dr V’s differential diagnosis for the rash was that it was caused by Mother A and B’s blood disorder or an infection. Both were subsequently eliminated.
  4. On the morning of 9 June 2015, Dr Gail Beech, a paediatric registrar, had discussed matters with the specialist registrar for haematology at the Level 3 unit at Alder Hey. This was just before Dr Saladi examined Baby B. That afternoon, the registrar at Alder Hey spoke again to Dr Beech. The registrar had spoken to “‘a couple’ of … consultants” and “they have recommended we send a coagulation screen” for Baby B. Later on, Dr Katherine Davis, a paediatric registrar, took a call from a consultant obstetrician who had discussed the case with Professor Hannah Cohen, a consultant haematologist in London. Professor Cohen had liaised with a consultant at Great Ormond Street Hospital and said: “feel death [of Baby A] is unrelated to [Mother A and B’s blood disorder] – would advise against [emphasis in original] any clotting or antibody screening”. Another junior doctor discussed the matter with Dr V, who advised holding off on the clotting screen that night.40 It is likely, therefore, that Dr V was aware of the death of Baby A by that stage. Dr V conceded that she did not take any steps to investigate Baby B’s deterioration.41

Discussions

  1. Dr Lambie said in evidence:
    “I do recall speaking with Dr Harkness after Child B had collapsed … because we were both very concerned about the similar nature of the collapse but particularly the unusual rash that neither of us had seen before. The children were also in very close proximity to each other, so we did discuss those concerns, were they related.”42
  2. The unusual rash/blotching on both Baby A and Baby B was a topic of wider discussion amongst the consultants. Dr Gibbs had heard about the rashes seen on both Baby A and Baby B during their collapses. In oral evidence to the Inquiry, he said: “The rashes in Child A and Child B were very strange and worried my colleagues and some of the Registrars.”43
  3. Dr Katherine Lyddon, then a relatively inexperienced junior doctor, now a consultant paediatrician, said: “I do recall discussions between the paediatric trainees … and NNU [neonatal unit] nursing staff that the rashes/skin changes seen in both babies was unusual and no one had seen anything similar before.”44
  4. Mother A and B told the Inquiry: “When Child B collapsed, I saw mottling/blotching on [the skin], as did the doctor.”45 She was made aware by a consultant that the rash on Baby B was unusual. She did not know then that Baby A had a similar body rash when Baby A died. In evidence, she said that if she had been told about the similarity in rashes on Baby A and Baby B at the time of collapse, she:
    “would have demanded that something was done … for some — a consultant to tell me they had never seen this before, that indicates that something is seriously wrong. Seriously wrong. Seriously wrong. And for it — it wasn’t just a one-off; it happened with Child A and then the very next day with Child B.”46

Text messages from Letby

  1. On 9 June at 19:03, Letby messaged Ms Taylor:
    “Oh don’t feel like that, I’m sorry you had to end your shift like that. I’ve said to Nurse T that I can’t look after [Baby B] because I just don’t know how I’m going to feel seeing the parents. Dad was on the floor crying Saying please don’t take our baby away when I took [Baby A] to the mortuary, it’s just heartbreaking. Glad the photos are nice X.”47
  2. From 11 June 2015, Letby sent separate text messages to a number of her nursing colleagues about Baby A’s death and about wanting to be back working in the intensive care unit. This would become a pattern of behaviour.
  3. On 11 June 2015 at 14:08, Letby messaged Ms Griffiths: “Are you okay for staffing over the next few days? I don’t have anything on if you need extra or need to change my nights X.”48
  4. At 17:35, Ms Griffiths replied to Letby that staffing was okay until Saturday, 13 June 2015.
  5. At 17:42 and 17:46, Letby wrote: “Ok. Think I need to throw myself back on Sat … think from a confidence point of view I need to take an ITU [intensive therapy unit] baby soon.”49
  6. At 17:50, Ms Griffiths replied: “yes it does knock us a bit when things like that happen. but its ok to have time out as well.”
  7. Ms Griffiths told the Inquiry that she “wouldn’t really tend to have a lot of conversations like this over the phone … I don’t have that experience on the unit that people say, ‘Can I get back into ITU’.”50
  8. On 12 June 2015, Letby texted Ms Hudson at 10:01: “Hi Ashleigh. You may have heard by now but wanted to let you know that we lost little [Baby A] on Mon. Know you looked after [Baby A] when [Baby A] was born so thought you should know xx.”51
  9. At 10:05, Ms Hudson responded: “I didn’t know actually, thanks for letting me know Lucy. That’s terrible! How is [Baby B]? xx.”
  10. At 10:08, Letby replied: “It was awful. [Baby A] died very suddenly & unexpectedly just after handover. Not sure why, it’s gone to the coroner. Child B went off Tue night & was intubated but back on cpap now. They are querying a clotting problem. Very sad. X.”
  11. At 10:23, Ms Hudson responded: “Oh god, [Baby A] was doing really well when I left.”
  12. At 10:27, Letby replied: “[Baby A] had a really good day on Mon then I took over Mon night & [Baby A] passed away at 20:58 after 30 min resus. Just collapsed very suddenly.”
  13. At 10:37, Ms Hudson replied: “It’s so terrible, and I’m sorry it happened while you were taking care of [Baby A]. You’re not having a great run at the moment!”
  14. At 10:41, Letby wrote:
    “I wasn’t supposed to be in either, Yvonne [Griffiths] swapped my night as unit busy! But these things happen unfortunately. Parents were there during resus. They had them both baptised then spent the night sitting with them both. I took pictures, hand/foot prints etc. They are beside themselves worried that they will lose Child B too.”
  15. In her evidence, Ms Hudson said she could “vividly remember” the text message exchange because it was “the first time a patient that [I’d] looked after had then passed away. I was also a bit angry because I didn’t think it was appropriate to get this information by text.”52 She explained that she “felt like it was too much information … that process afterwards is a very important and sensitive time. I don’t — didn’t feel like I needed that information.”53
  16. On 13 June 2015, at 21:48, Letby wrote to Ms Jennifer Jones-Key, a neonatal nursery nurse (band 4): “I just keep thinking about Mon. Feel like I need to be in [Nursery] 1 to overcome it but Nurse W said no x.”54
  17. At 21:51, Ms Jones-Key replied: “I agree with her don’t think it will help. You need a break from full on ITU.”
  18. At 21:55, Letby replied: “Just feel I need to be in [Nursery] 1 to get the image out of my head, Mel [Taylor] said the same and Nurse W let her go. Being in [Nursery] 3 is eating me up, all I can see is [Baby A] in [Nursery] 1 X.”
  19. At 21:56, Letby wrote: “It probably sounds odd but it’s how I feel X.”
  20. Ms Jones-Key replied: “Well it’s up to you but don’t think it’s going to help. It sounds very odd and I think I would be the complete opposite. Can understand Nurse W she is trying to look after you all x.”
  21. Ms Taylor was referred to these messages when giving evidence. She denied requesting to be back in Nursery 1. She commented: “[M]y personal experience was I found it [Baby A’s death] extremely traumatic and difficult. I found it difficult to go back into work. And I wouldn’t have wanted to voluntarily go back into Nursery 1.”55
  22. Mother A and B said there were “several text messages [of Letby’s] that came out through the trial that were lies”.56 She gave the example of Letby saying in a text that Father A and B had collapsed to the floor when Baby A was taken to post-mortem. This was a reference to the text message Letby sent to Ms Taylor on 9 June 2015, including the words: “Dad was on the floor crying Saying please don’t take our baby away when I took [Baby A] to the mortuary.”57 Mother A and B was clear that that was not true and did not happen. In her view, Letby’s messages were “attention seeking” and a “red flag”. I agree with her.

Baby C

Mother C: “[T]o hold him was a really big thing for us. It was very emotional, and I — you know, I hadn’t had a baby before, and I didn’t really anticipate all the feelings that I would have when I held him, and that immediate bond that you feel that, you know, I couldn’t describe now but I certainly didn’t anticipate. It was a really amazing feeling.”58

  1. Baby C was born by caesarean section at 30 weeks and 1 day’s gestation. His growth in the womb had been slow and he weighed 800 grams at birth, a low weight for this gestation. Mother C said that she and her baby were:
    “very closely monitored under the care of foetal medicine, that was predominantly Jim McCormack, and the foetal medicine midwife at the time was Jill Ellis [an advanced midwife practitioner]. They saw us very regularly and gave us really excellent support, we were very grateful for that, but the pregnancy was very precarious, really. The scans were to monitor growth but also to monitor blood flow to weight, up until the point where the situation was critical and the baby would need delivery.”59
  2. During the course of her pregnancy, Mother C asked Dr McCormack whether she needed to be transferred to somewhere like Liverpool Women’s Hospital or a different unit. Dr McCormack reassured her that he did not feel that was necessary. He would continue to monitor things closely and, if that changed, he would change the plan.
  3. Baby C, though very small, was born in good condition; no resuscitation was required. He was taken to Nursery 1 on the neonatal unit. Dr Sally Ogden, a paediatric registrar, told his mother in theatre that Baby C was “doing really well, he was born in good condition”.60 Dr Ogden also told her that Baby C was ventilated for a brief period and then began breathing by himself.
  4. Like Mother A and B, Mother C was unable to see her baby for some time after birth – in her case because the midwife had told her that she had to be able to stand up unaided to go and see him. She had had an epidural injection and a caesarean section. Obviously, she could not stand up. It may be that the midwife thought she should rest, but she had not seen her baby; nothing would have been more important. She could and should have been taken down to the ward (which was on a different floor) in a wheelchair. After six or seven hours of not seeing her newborn baby and of receiving updates from her husband and the doctor, she forced herself to stand, “because I needed to go and see him”.61
  5. Mother C said that, in the days after Baby C’s birth, she and her husband saw a lot of Dr Gibbs. He was very open and honest with them. He said that Baby C was:
    “very small for his gestation and that that represented certain risks such as an increased risk of developing infection and an increased risk of a particular bowel complication called necrotising enterocolitis, but that he was born in very good condition, he was making good progress, and he was doing well. He expressed to us that although babies of … that size at that gestation — were at risk of these complications that, his prognosis was good and that he was not expected to die.”62
  6. Nurse W was the team leader for the night shift of 13/14 June 2015 and it was her responsibility to allocate nurses to the babies. Ms Sophie Ellis, a neonatal nurse (band 5), was Baby C’s designated nurse that night. Ms Taylor was also working in Nursery 1, caring for a different child and overseeing Ms Ellis, who was less experienced. Letby was working on the night shift but was caring for a different child in Nursery 3. Letby made it clear to Nurse W that she wanted to be in Nursery 1 rather than Nursery 3. This was consistent with her text messages and her later behaviour.

Collapse

  1. When the alarm sounded for Baby C, Ms Sophie Ellis went from the nurse’s station into Nursery 1. Letby was already there, standing next to Baby C’s cot. A short time later, Baby C had a prolonged period of bradycardia and desaturation. The nurses started resuscitation and put out a crash call for the on-call doctors. Ms Ellis recalled Letby saying, “He’s going.”
  2. Dr Davis, a registrar, had “received a ‘crash call’” to attend to Baby C at about 11pm.63 When she arrived, resuscitation was already under way. As the senior doctor, she took over leading the resuscitation attempts and asked for the on-call consultant, Dr Gibbs, to be alerted and to attend. She told the Inquiry:
    “[T]here was no obvious explanation as to what may have caused Child C’s unexpected collapse … The lack of explanation for the collapse was unusual but more unusual was the lack of response to resuscitation and the complete lack of a heart rate at the time of my arrival. I had managed a number of neonates in need of resuscitation by that point in my career, and they usually have a slow heart rate, rather than an absent one … [T]he total absence of a heart rate despite effective airway management, chest compressions and resuscitation medication [was] not something I had experienced before, or indeed since.”64
  3. Dr Gibbs arrived ten minutes into the resuscitation.65 He described how Baby C failed to respond to resuscitation and was then given “a limited form of resuscitation” in order to await attendance of the chaplain to baptise Baby C. He and Dr Davis noted that, during this period, Baby C “began to make occasional, abnormal gasping respiratory efforts and a slow heart rate was heard intermittently”. However, after discussion with his parents, it was agreed that no further full resuscitation would be offered. Baby C died several hours later at 05:58.
  4. Dr Davis said:
    “[W]e stopped chest compressions and ventilation breaths … Child C continued to show signs of life with some spontaneous breaths and a good heart rate. The fact that this happened following a prolonged period of chest compressions without the use of medication and without any response to earlier efforts when drugs were used was highly unusual. I was unable to think of any medical explanation why this had happened. I would have discussed this with Dr Gibbs.”66
  5. Mother C gave evidence that, at around 11pm on 13 June 2015, she was woken up by a panicked midwife “telling me that I needed to come immediately because my son had become unwell really quickly”. She got herself to the room where Baby C was and “was faced with … it was awful … There were medical personnel everywhere.”67 The only one she knew was Dr Gibbs. She recalled that when she arrived on the neonatal unit, staff were performing CPR on her baby. She sat down. A nurse asked her if she would like her to call a priest. Mother C recollected asking the nurse: “‘Do you think he’s going to die?’ And she said, ‘Yes, I think so.’ And at the time — you know, as I say, I didn’t know this nurse’s name, I hadn’t seen her before, but I believe this was Lucy Letby.”68
  6. Mother C confirmed that limited resuscitation continued until the priest arrived and baptised Baby C some 50 minutes later.* Afterwards, Parents C went to the family room with Baby C, where they held him for several hours until he died. Some other family members were with them, including Baby C’s maternal grandmother. During the hours that Baby C was alive, his mother was sure that he was in pain. She insisted that he be given some pain relief, which was, in the end, administered, and he settled peacefully for his final hours.69
  7. Mother C said that at this time two nurses were coming in and out of the family room while Baby C was with his family. One was Ms Taylor, to whom the care had been transferred, and the other was Letby.70 Mother C explained that they were:
    “creating things for a memory box. So taking Child C’s hand and footprints, taking a bit of his hair, and checking on us. So my understanding at that time was that they were designated to do that, and it was only at the criminal trial that I realised that that was not the case, that Lucy Letby was specifically designated not to do that, and she was supposed to be somewhere else and was repeatedly told to be looking after a different child.”71
  8. Nurse W explained in evidence that, having assisted with the resuscitation, Letby “kept trying to help Melanie Taylor, who is more senior than her and more than capable”. Nurse W noted that on several occasions she had to insist that Letby return to care for her allocated child.72 Nurse W described Letby as “consumed with Baby C and wanting to be in the family room with Baby C and that family even though I distinctly asked her to not be in there”.73
  9. Nurse W was concerned about Letby assisting Ms Taylor to take Baby C’s hand and footprints following his death, rather than caring for her allocated child. In oral evidence, Nurse W stated: “[S]he [Letby] didn’t need to be there. Mel [Taylor] was more than competent to be there at that family support.”74 Ms Taylor, in her evidence to the Inquiry, said that Letby “wanted to help rather than look after the baby she’d been allocated”.75
  10. Nurse W discussed the incident with Ms Taylor during the night and with Ms Powell, her manager, the next morning. Nurse W reported Letby not following instructions to Ms Powell and informed her that babies’ care in Nursery 3 was compromised as a result.76 Nurse W said she would have expected Ms Powell to speak to Letby about her behaviour; however, she did not know if this happened. She could not recall receiving any feedback from Ms Powell about her concern.
  11. In oral evidence, Ms Powell emphasised the importance of an allocated nurse staying with their child.77 She acknowledged that Nurse W had informed her that Letby was not staying with her allocated child and was instead trying to be involved in Baby C’s bereavement care. She said Letby’s behaviour was a serious breach of protocol.78 Despite this, Ms Powell had no recollection of speaking to Letby about the incident.79 It is most unlikely that she did so. She did, however, recall that she “asked Nurse W to do a Datix and have it documented”.80 However, the Datix report that was completed was in relation to Letby’s allocated child under the category of delayed treatment. Nothing was done about Letby repeatedly ignoring directions from the shift leader and leaving the other child to intervene with Baby C. This was a failure by Ms Powell for which she had no explanation. It is likely that her judgement was affected by her view that Letby was a very good nurse (she was later to describe her as the “crème de la crème”) and that she was always available for extra shifts.81

Letby’s final intervention with Baby C

  1. Mother C said that, while Baby C was still alive, Letby prompted her to put him in a ventilated Moses basket, known as a cold cot. Mother C recalled: “I remember the cold cot being plugged in … we were in this really difficult situation where, you know, our son was dying, and it was certainly jumping the gun to bring that in and plug it in.”82 Father C was rightly very curt with Letby, who swiftly left the room. In the parents’ joint statement, he said: “Reflecting on it now, I believe she wanted to savour my son’s dying moments for herself, which fills me with both emotion and anger. Had I not challenged her, she would have further intruded on our private goodbye to Child C.”83
  2. Ms Taylor was not in the family room when the incident with the cold cot happened. She first heard about it during the criminal trial. She stated that she was “horrified” to hear that Letby had said words to the effect of: ‘It’s time to say goodbye now and put him in this cot.’84 In her view, it was an “uncompassionate and cold” comment. It was not aligned with the team’s ethos of following grieving parents’ wishes to spend time with their child or make memories.85 Similarly, Nurse W was “absolutely horrified” and “deeply upset” to learn about the incident.86

Responses to Baby C’s death

  1. In oral evidence, Dr Gibbs confirmed that Baby C’s death on 14 June 2015 was sudden, unexpected and unexplained.87 He added that in his 21 years’ experience, sudden and unexpected deaths were “occasional, every few years”.88
  2. Letby was convicted of the murder of Baby C.
  3. Ms Sophie Ellis was stunned by the collapse and death of Baby C, recording in her police statement: “[W]e don’t know, even now what caused Child C’s collapse and ultimate death.”89 Ms Ellis recalled that, following the death of Baby C, there was an informal debrief at the end of the shift.90 A more formal debrief was then led by Dr Gibbs some weeks later on 2 July 2015.91 An email was sent out by Ms Powell, Manager of the neonatal unit, to Letby and the other nurses on duty, inviting them to attend “only if you want to”. The notes of this debrief are in Baby C’s medical notes. It is recorded that Ms Powell, Ms Taylor, Dr Davis, Ms Ellis, Dr Gibbs and Letby attended. There was a discussion about the events leading up to Baby C’s death and that he “did not seem unwell”.
  4. Dr Gibbs said in evidence that Baby C had been born in a good condition at 30 weeks and 1 day and was expected to survive. From a respiratory point of view, Baby C was improving in the days leading up to his collapse and would not have been expected to have any significant problem at that stage from his breathing. Dr Gibbs also noted that blood cultures did not show any sign of infection, something confirmed in the post-mortem.92 Dr Gibbs pointed out that Baby C showed no response to resuscitation. In oral evidence, he explained this reaction would be expected in a child who had been poorly for a while and had no reserves left. However, this was not the case with Baby C. Dr Gibbs said: “[I]t is unusual from a sudden collapse in the baby that was managing well beforehand not to get a response to resuscitation.”93
  5. Dr Gibbs referred Baby C’s death to the coroner’s office.94 He explained that he did this because he “didn’t know why Child C had collapsed and died”.95 A post-mortem examination was carried out at Alder Hey on 16 June 2015 by Dr George Kokai, a consultant paediatric pathologist. On 14 August 2015, Dr Gibbs spoke to Dr Kokai on the phone about his preliminary findings about Baby C. Dr Gibbs explained in evidence that Dr Kokai considered Baby C had died from myocardial ischaemia, and that the heart damage had predated and could have caused Baby C’s collapse.96 Dr Gibbs explained to the Inquiry that he:
    “wasn’t sure whether the damage to the heart that was noticed on this postmortem would have all happened at and after the resuscitation or whether it happened before. It was Dr Kokai’s view that the damage to the heart had happened before the resuscitation and therefore caused the collapse but it didn’t fully explain it because I then asked ‘but why did the damage occur to the heart?’”97

Dr Gibbs added that myocardial ischaemia “didn’t quite fit together” with Baby C’s history.98

  1. A coronial investigation was commenced for Baby C on 14 June 2015. Dr Kokai’s post-mortem report was received in November 2015; he had concluded there was a natural cause of death. As a result, the investigation was discontinued on 26 November 2015.99
  2. Although he was not satisfied by Dr Kokai’s explanation for Baby C’s death, Dr Gibbs did not have any concerns about deliberate harm at the time. He explained: “[S]adly it had been my experience even after postmortem it is not always possible to explain a death and that is occasional.” However, he added: “[W]hen that situation keeps arising, something very strange is happening.”100

Other reports and reviews

  1. Baby C’s death was reported as a Datix incident by Ms Griffiths. The Datix description refers to the “sudden deterioration of an infant following full resuscitation”.101 In fact, Baby C deteriorated suddenly and then did not respond to full resuscitation. Nothing turns on this error.
  2. The death of Baby C was also referred to an Executive Serious Incident Review to be held on 2 July 2015, at the same time as a review of the death of Baby A and the death of Baby D (who died eight days after Baby C).102 See further in Chapter 4.
  3. The death of Baby C was reported to the CDOP on 15 June 2015. There was a significant backlog of cases, so Baby C’s death was not reviewed by the panel until 23 March 2016. The panel identified no issues, made no recommendations and identified no learning points or actions.
  4. In her evidence, Mother C said: “[T]hat night [Baby C died] and everything that has happened since have left an indelible mark.”103
  5. She told the Inquiry: “[T]hat there had been another death that week, I had no idea until the criminal trial. I had no idea that there were various text messages flying around about the death of our son and the other collapses.”104

Baby D

Mother D: “My pregnancy was smooth, apart from the odd pain that people get. There was no concern, no issues. I was towards the end of my pregnancy just over three weeks, so my daughter was a good size baby. She was pretty much — I was almost full term so everything for me was in place. Everything was ready. The nursery was sorted. I crafted everything in the room. I painted, I decorated, I made everything. Only we knew the name, so we had like a little reveal ready. Everything was ready in the house. So we were just on the little cloud nine.”105

  1. Mother D and her husband had been looking forward to the birth of their baby. The pregnancy had been straightforward and was at 37 weeks and 1 day’s gestation.
  2. Mother D’s waters broke at 03:30 on 18 June 2015. She went into the maternity unit at 11:30, was monitored and then advised to go home until her contractions started. She was told she would be booked in for the following morning. Mother D returned to the hospital on 19 June. She was concerned about infection because it was now 30 hours since her waters had broken. She was admitted and received treatment during the day. Contractions did not begin. Mother D was started on an intravenous induction on 20 June. Labour did not progress and Mother D became more and more anxious, repeatedly asking for a caesarean section as she was worried about her baby, she was exhausted and labour was not progressing. She told me that midwives dismissed her concerns and told her to be patient. She felt she was not listened to. A doctor tried to reassure her but then agreed to perform a caesarean section because labour was not progressing. Mother D said that it felt like a real emergency. Baby D was born in good condition, with Apgar scores† of 8 after one minute and 9 after five minutes, and weighed 3.13 kilograms. After a short while, Mother D was concerned about Baby D because she was grunting and appeared floppy. She was observed by nursing and medical staff over the next three hours, and at 19:00, Baby D was admitted to the neonatal unit on Nursery 1, antibiotics were administered and she was given light therapy for a period.
  3. Ms Oakley was the designated nurse for Baby D on the night shift of 21/22 June 2015. Letby was caring for two different babies in Nursery 1. Ms Oakley said in her witness statement to the Inquiry: “Dr Brunton reviewed Child D at the start of his shift, and he was happy with her status too.”106 Dr Andrew Brunton, then a paediatric registrar, now a consultant neonatologist, confirmed that he had reviewed Baby D at 21:10 and was not concerned for her. Mother D said that Dr Brunton reassured her and her husband that “everything’s fine, she’s much better. She’s come off the light therapy. She’s picking up. She seems to be more lively.” Mother D said: “[T]hey said: if all carried on, continue expressing milk, and if all carries on, tomorrow morning you can breast feed her and you can have a cuddle and that’s that. She’s on her way to recovery … full recovery.”107 Mother D could see that her daughter looked better and went back to bed.

Collapse and skin changes

  1. At 01:30, Baby D unexpectedly collapsed. Ms Oakley was called back to the nursery by Ms Percival-Calderbank, who had been covering her break.108 Dr Brunton was paged to attend the neonatal unit to examine Baby D. Dr Brunton attended immediately: “I noted that there were significant areas of light brown/dark brown and black lesions tracking across the trunk. Given that that the rash itself was unusual, in conjunction with the short episode of increased support for Child D’s breathing, I contacted the Consultant on Call.”109 Dr Elizabeth Newby, a consultant paediatrician, was the consultant on call.
  2. Both Ms Oakley and Ms Percival-Calderbank referred to the unusual skin discolouration of Baby D, described by Ms Oakley as blotchy and appearing over the trunk and top of her legs. Ms Oakley’s evidence was that “around that time there was a cluster of similar rashes that had appeared on other babies on the unit”.110
  3. Dr Emily Thomas, then a junior doctor (paediatric specialty trainee), who was also on the night shift, recalls being called from the children’s ward by Dr Brunton because Baby D had a very unusual rash. Dr Brunton told her that he had never seen a rash like this before and asked if she had. In her statement to the Inquiry, Dr Thomas, now a consultant paediatrician, confirmed that she had not seen a rash like that before, but given that she was very junior, there were many things she had not previously seen. Importantly, however, she said that she had not “seen such a rash since”.111
  4. Mother D recalled staff being unsure about the cause of the rash on Baby D. She told the Inquiry: “[T]he mottling on my daughter, — they told me clearly they don’t understand, they’ve never seen this, they don’t know what’s going on.”112
  5. Dr Brunton requested abdominal X-rays and blood tests and discussed these with Dr Newby.113 Baby D initially improved and was considered stable by Dr Brunton at 02:35. At 03:15, she deteriorated again and Dr Brunton was recalled. Again, she stabilised. However, at 03:45, Baby D collapsed for a third time and stopped breathing. Letby was present at the resuscitation of Baby D.114 Dr Thomas was already on the unit and she assisted with the resuscitation. At 03:55, Dr Brunton was called back to the unit. He attended and asked for Dr Newby to be recalled. Dr Brunton had called her because, as well as the unusual rash and the need for increased breathing support for Baby D, he “had concerns that this was an unusual pattern of behaviour for a baby who had been clinically stable previously”.115 He went on to say: “It was completely unclear to me as to why Child D had suffered dramatic deteriorations in her clinical condition punctuated by periods of being completely stable … Child D’s episodes of deterioration and subsequent death were completely unexplained.”116 In her evidence to the Inquiry, Dr Newby referred to lesions on Baby D’s abdomen and explained that she considered Baby D’s death to be an unexpected event that she could not fully explain.117
  6. Mother D was woken up by one of the nurses, who told her: “You need to come now, your daughter is very poorly.”118 She arrived on the neonatal unit to the sight of Dr Brunton holding Baby D and trying to save her. Baby D did not recover, and at 04:25 on 22 June 2015 she died. Parents D were told that there would need to be a post-mortem. Mother D remembered: “[W]e were told that’s because they don’t understand what happened, and why it happened. So they need to investigate.”119
  7. Ms Oakley described Baby D’s death as “unexpected”, saying: “I remember feeling happy with her at the start of the shift … I remember thinking she looked well.”120
  8. Letby was convicted of the murder of Baby D.
  9. Dr Newby said in evidence that she had independent recall of the last 24 hours of Baby D’s life because “it’s very unusual to get a death on a neonatal unit, particularly a child that’s not known, for example, to have significant congenital abnormalities”.121 She described Baby D’s death as “very difficult and traumatic” for staff working that night shift.122
  10. Mother D said that she felt that Letby was observing them when they were with their daughter after her death. She described Letby as out of place and that her presence made Mother D feel uncomfortable.123 Mother D said that later, at the criminal trial, she:
    “found out that [Letby] looked us up, both my husband and I … she should have had no reason to go and look us up. And the conversations she had by text message with colleagues about my daughter and how she called this ‘fate’, and that ‘sometimes things happen’, this I found shocking, because after what she’s done, this is disgusting.”124

Report to the coroner

  1. Dr Newby reported Baby D’s death to the coroner’s office on 22 June 2015. She could not recall the exact details of the conversation; however, she thought that she would have reported that “it was an unexpected event that I couldn’t fully explain” and that she “wanted a postmortem in order to for everybody, really, for myself and for the family to — to help everybody to understand what had happened”.125 Dr Newby stated that she would also have mentioned the lesions on Baby D’s abdomen. Her account is confirmed by the coroner’s authorisation form, which sets out the information reported by Dr Newby: “Dr cannot offer COD [cause of death] – sudden and unexpected.” Under the heading ‘additional information’, it is recorded: “[J]ust before 4am, she went profoundly mottled and apnoeic, lost heart rate.” Dr Newby also informed the coroner of the deaths of Baby A and Baby C and the collapse of Baby B. The form reads: “Reported that this had been 3rd death in 12 days for neonatal. Also a further episode of apnoeic event and CPR for previous twin death; surviving twin had successful CPR.”126
  2. On 23 June 2015, Dr Jo McPartland, a consultant paediatric pathologist at Alder Hey, conducted a post-mortem of Baby D. The original report was dated 26 August 2015. Dr McPartland then produced a supplementary report on 17 September 2015. She concluded that Baby D’s cause of death was pneumonia with acute lung injury.
  3. Despite reading the information on the form about three deaths in 12 days and a further episode of apnoeic event and CPR, Dr McPartland did not think this was enough to raise suspicions. She stated: “I wasn’t informed that the same staff member was involved.”127 She considered that, in order for concerns of deliberate harm to be picked up at the coronial stage in the referral, it would require someone directly to say: “[T]here is an increased number of worrying deaths and we are worried that the same staff member has been involved in all of them.”128 Dr McPartland told the Inquiry that she would need a “strong clinical steer that it was a suspicious case to warrant insisting on police and forensic pathology involvement”.129 As a result, she treated the fact that there had been three deaths and a non-fatal collapse in 12 days as irrelevant to the post-mortem. She did not seek to discover why this information had been provided when she did not consider it relevant. It is likely that had she asked, she may have been told: ‘Three deaths is the equivalent of our usual annual number of deaths. They were all unexpected and we are worrying about them.’ Nothing would have been said about an individual nurse because Dr Newby did not have those concerns at that time, nor did anyone else. She would have described Baby D’s death as “very unexpected”130 and, at the time, she thought she was “working within a medical model, there was evidence of sepsis”.131 It is unlikely therefore that Dr McPartland would have arranged a forensic post-mortem.
  4. Dr Newby’s letter to Parents D, dated 19 August 2015, summarises their meeting on 17 August 2015 and records that the post-mortem results were not yet available. Dr Newby wrote: “[W]e felt as a department that the most likely diagnosis was one of sepsis, ie; overwhelming infection.”132 The letter also records that Dr Newby and Parents D “discussed the aetiology of the rash which is documented to have appeared during Child D’s first episodes of deterioration. This appeared to look like bruising under the skin and we discussed that this was likely a sign of the effect the infection was having upon Child D’s circulation.”133
  5. Mother D said in evidence that she challenged Dr Newby about the sepsis diagnosis: “I said, ‘Well, you explain this to me because if an infection is that overwhelming that it will kill a baby but doesn’t show on the reading, this does not make sense. She was getting better. Not getting worse. Again, explain.’ She couldn’t explain.”134 Dr Newby confirmed this discussion took place between her and Mother D and acknowledged that sepsis did not appear in the test results. She said: “[A]lthough we felt that [Baby D] did have an infection and she was septic as she presented that way, the blood cultures hadn’t proven that.”135

Text messages from Letby

  1. At 08:39 on 22 June 2015, a few hours after Baby D’s death, Letby texted Nurse T: “We lost Child D.” Nurse T responded: “What!!!! But she was improving. What happened.” At 08:41, Letby told Nurse T via text that Baby D “came out in this weird rash looking like overwhelming sepsis”.136 Nurse T told the Inquiry that reading Letby’s message did not make her think of the rash on Baby A and Baby B because, in her opinion, the rash on the twins did not look like a sepsis rash.137
  2. At 08:48 on 22 June 2015, Nurse T messaged Letby, stating: “[Y]ou’ve had it all recently.”138 In oral evidence, Nurse T explained what she meant by this message: “I knew she was there for [Baby] A, I knew she was there for [Baby] B, because she was with me. I knew she was on duty when Child C died because she told me, and here we are, what, within a fortnight, and she’s there for Child D as well.”139

Dr Brearey and Ms Powell: Mortality review

  1. On 22 June 2015, the day Baby D died, Dr Brearey met Ms Powell to conduct a mortality review into Baby D’s death. Ms Powell said that she and Dr Brearey discussed whether one person was there for all the deaths because they were suspicious about three deaths happening so rapidly and unexpectedly. She thought that it was Dr Brearey who raised this first.140 Dr Brearey thinks it was Ms Powell. It does not matter which of them it was. They were both thinking along the same lines at that point and Letby’s presence was acknowledged at that time. The shift patterns were not written down until 23 October 2015, the day Baby I died.
  2. At 19:41 on 22 June 2015, Dr Brearey sent an email to Dr Jayaram, copied to Ms Powell, explaining that he had reviewed Baby D’s death with Ms Powell:
    “Just to confirm that I have met with Eirian [Powell] and reviewed the case notes of Child D … who died in the early hours this morning. We have also discussed whether there are any other issues to address in view of the two other recent sudden deaths on NNU [neonatal unit].
    …
    There does not seem to be any staff (medical or nursing) members present at all three episodes other than one nurse, who was not the nurse responsible for Child D on that shift [emphasis added].”141
  3. The email then sets out details of Baby D’s care and then this:
    “I would be very surprised if Child D’s death is linked in any way to the previous recent deaths of Child A and Child C.
    We have agreed an action plan however [emphasis added]:
    1. I will review Child A and Child C’s case notes in detail this week.
    2. I will review Child A’s preliminary PM report which I have not seen yet.”142
  4. It is clear, therefore, that by 22 June 2015, the day of the third death, Dr Brearey was aware of an unusual increase in deaths on the unit, even though he had not been involved in looking after any of the babies. He knew that a review was needed and that one nurse had been present at all three episodes, and he knew who she was, as did Ms Powell. It is equally clear that, at that stage, he did not think there was a link between the death of Baby D and those of Baby A and Baby C, but, as he said in evidence, he was aware of the association with the nurse “and it was more of a growing nagging concern”.143
  5. Dr Brearey was asked by Mr Richard Baker KC, Counsel for Family Groups 2 and 3, whether he should have included a review of Baby B’s case notes in his action plan. At the time, Dr Brearey did not think that was necessary because he had seen Baby B clinically and had scanned Baby B’s heart, so a review would not add information he did not already have. Whilst that was a reasonable approach to take at the time, hindsight reveals that it meant he did not know about the expert view (expressed in the notes of Baby B) that Mother A and B’s blood disorder was unlikely to have contributed to the death of Baby A (see paragraph 3.16).
  6. A Datix entry was made recording the death of Baby D.144 This noted the mottled skin prior to death.

Junior doctors’ concerns

  1. Dr Lambie raised concerns about Baby A and Baby B with various consultants “a number of times”. She stated: “[E]ach time I had a very positive response and I was very much under the impression that they were listening, they shared our concerns and they were being dealt with.”145 Dr Lambie recalled having an informal conversation in the coffee room with Dr Newby about the rash. She stated that Dr Newby approached her to find out more information about it.146
  2. Dr Newby recalled speaking to Dr Lambie, Dr Brunton and Dr Harkness about the rash that was observed in Baby A, Baby B and Baby D; she stated: “I knew that the trainees were very concerned about it and we were very concerned about it as well.”147
  3. On 23 June 2015, Dr Gibbs sent the following email to the consultant paediatricians:
    “Rachel Lambie came to see me this morning (I think because I was the only person in the office when she came), to say that the Registrars are very concerned about the recent neonatal deaths and collapses (Child B) where all the infants showed a strange purpuric looking rash (that probably wasn’t true purpura). However, I pointed out that Child C who also died did not have this rash – but it’s true the Child A, Child B and the recent death (Child D), did show a similar strange colour change on ‘collapsing’. Rachel also said that ‘all’ the neonatal nurses are very worried. They feel we ‘ought to be doing something’ and also asked what else different the Registrars can do.
    I explained that we were looking into this worrying spate of deaths (and Child B’s collapse), but at the moment couldn’t identify a unifying cause.
    …
    Do we need a meeting with the neonatal nurses (or are you arranging this anyway, Steve [Dr Brearey]). I think a meeting would be useful, even if we have no answers – just to let the nurses air their concerns and to show we are concerned also (since clearly the nurses are worried and talking about this with the Registrars and the perception seems to be that we’re not doing anything active at present). So, even though we don’t have answers, just meeting with the nurses (and also perhaps the Registrars), might be helpful.”148
  4. Dr Newby responded to Dr Gibbs’ email later that same morning on 23 June 2015: “I agree, I have just been grilled by Dave Harkness. This is causing a lot of concern/upset. Can we pull something together fairly soon? I think we need to meet with both-probably separately would be better.”149
  5. Dr Newby informed the Inquiry that Dr Harkness was “very concerned about the three deaths and he also mentioned the link between the … rashes that were seen on each baby”.150
  6. On 23 June 2015, Dr Newby sent another email to Dr Brearey and the consultant paediatricians suggesting that Baby A, Baby C and Baby D be reviewed together at the perinatal mortality and morbidity meeting the next day. Dr Brearey declined this suggestion and wrote that he wished to review only Baby A and discuss the other two afterwards.151 Dr Brearey explained in evidence that there was limited time available to discuss more than Baby A because two other babies were already scheduled to be discussed in the meeting. Also, at the time he thought that the three deaths (of Baby A, Baby C and Baby D) had different causes.152 This was consistent with his email to Dr Jayaram on 22 June 2015 (see paragraph 3.103). Dr Brearey accepted that, in retrospect, it might have been helpful to review all three deaths and Baby B’s collapse with the registrars present.153
  7. Counsel asked Mother A and B for her thoughts on how the rashes were investigated. She replied: “[F]or everybody to be so shocked and never ever seen this before, why was something more not done about it? Because it wasn’t just Child A and Child B.”154

Senior clinicians’ meeting

  1. On 29 June 2015, there was a senior clinicians’ meeting attended by the consultant paediatricians, Ms Anne Murphy and Ms Powell. It is recorded in the meeting notes that the registrars had been worried about the three recent neonatal deaths: “There was also an issue raised around the fact that with the three recent neonatal deaths, the Registrars had been quite worried and feel that nothing is being done. Behind the scene reviews are going on but it was felt that formal debriefs should probably take place, rather than any specific meeting to discuss all three.”155 At this time, Dr Newby did not have concerns of deliberate harm; she said: “[W]e were concerned that we had some bug on the unit, maybe contamination of some equipment, one of the ventilators, for example, so we were extremely concerned about it.”156 Dr Gibbs also stated that his main concern at this stage was that there was a bug on the neonatal unit or contamination of feeding fluid.
  2. The doctors and nurses undertook various investigations to rule out whether any environmental factors explained the neonatal deaths. The following were excluded as causes of the deaths: (a) equipment on the neonatal unit; (b) infection; (c) pseudomonas; (d) respiratory syncytial virus (RSV) outbreak; and (e) staff competencies.

Nurses’ concerns and messages with Letby

  1. There was understandable concern amongst the nurses too about three sudden and unexpected deaths occurring so closely together. Nurse T expressed her concerns in a WhatsApp message to Letby on 30 June 2015. Nurse T wrote to Letby: “There’s something odd about that night and the other 3 that went so suddenly.” Letby responded to this with the following: “Odd that we lost 3 and in different circumstances?” Nurse T responded: “Were they that different? Ignore me. I’m speculating.”157
  2. In evidence to the Inquiry, Nurse T confirmed that by “odd” she meant Baby B’s collapse and the deaths of Baby A, Baby C and Baby D were “highly unusual”.158 She stated: “[I]n all my 15 years to then and 25 years to now, I have never seen three babies die so suddenly in such a short space of time.”159 Nurse T confirmed that these events did not cause her to have any suspicions.
  3. Nurse T said that she did not share her thoughts with anyone other than Letby, noting: “There was no formal debrief.”160 Similarly, Ms Powell could not remember any specific conversations about the deaths or the commonality of the rash at the time of the children’s collapses.161 However, she recalled staff speaking to her about “how upsetting” the deaths were and that they were “unexpected”.162 Ms Powell had also “picked up that there’s anxiety there about the unexplained deaths”.163 She had never experienced three unexpected deaths and one collapse in such a short period in her career.164
  4. Ms Griffiths gave oral evidence that, after Baby D’s death, “I think everyone was trying to look for, for reasons why we had so many close together and I think Nurse Oakley commented about the skin discolouration.”165 She described the staff thought process as follows: “We didn’t suspect at that time any harm, but is there something that we are unaware of?”166

Dr Gibbs

  1. In oral evidence, Dr Gibbs confirmed:
    “There were informal discussions between Consultants around July 2015, several had been involved with the death on the NNU [neonatal unit]. It was recognised that Letby had been present on each occasion … [I] felt sympathy for Letby at that time because [I] felt she had been unlucky to have been involved in a number of incidents.”167
  2. Dr Gibbs knew that Letby worked more shifts than others and at that time he believed that she was unfortunate to have been involved in the cluster of deaths. He explained that he thought Letby was on a “bad run”, which can sometimes happen, “but then that stops happening if it is just an unfortunate coincidence”.168
  3. On 2 July 2015, Dr Gibbs conducted a debrief and meeting in respect of Baby C. It was recorded on a pro forma document headed ‘Sudden Unexpected Death in Infancy and Childhood (SUDIC) initial strategy meeting’. Dr Gibbs made it plain that this was not a SUDIC meeting. In his view, SUDIC did not apply to Baby C; the pro forma was a convenient way of recording information to be reported in due course to the CDOP.169 I deal with SUDIC in Chapter 12.

Dr Brearey’s review of Baby A, Baby C and Baby D, 1 July 2015

  1. Dr Brearey, Ms Debbie Peacock (Risk and Patient Safety Lead for the Women and Children’s Division) and Ms Powell carried out a case note review of the deaths of Baby A, Baby C and Baby D on 1 July 2015. Dr Brearey produced individual reviews for each child and a summary report dated 1 July 2015.170 In the individual review of Baby A, and in the summary report, there is reference to Baby B having a respiratory arrest 24 hours later but responding to resuscitation: “[C]ollapse of twin 1 24hrs later with successful resuscitation.”171 The section of the summary report relevant to Baby A was subsequently sent to the coroner. It did not suggest any cause of death, but stated: “Awaiting full PM report. Preliminary report did not identify any macroscopic abnormalities. UVC in liver but no significant clots present and no perforation.” In respect of Baby C, the summary conclusion was: “Awaiting PM but likely diagnosis of acute bowel obstruction and/or sepsis with background of extreme prematurity and IUGR [intrauterine growth retardation].” The summary also set out learning, including points for discussion and improvement in practice. They were not likely to have influenced the outcome.172
  2. Ms Powell confirmed that the rashes were not discussed in the review.173 Dr Brearey told the Inquiry that he regretted not paying more attention to the rashes and skin abnormalities in Baby A, Baby B and Baby D when he conducted this review. He also acknowledged that a case note review has limitations because it does not involve speaking to clinicians involved in the care.174 This limitation would be seen again in 2016, but on that occasion in respect of a review completed by an expert brought in by Mr Harvey.
  3. Towards the end of the case note review, Dr Brearey set out the Countess’s annual neonatal mortality data over the previous seven years.175 The figures were:
    • 2008 = 4
    • 2009 = 1
    • 2010 = 1
    • 2011 = 3
    • 2012 = 3
    • 2013 = 2
    • 2014 = 3.
  4. He explained that he did this in anticipation of the Serious Incident Panel meeting scheduled for the next day, knowing that Ms Kelly and Ms Ruth Millward (Head of Risk and Patient Safety) would be there. He said in evidence to the Inquiry: “[K]nowing what our annual mortality rate is historically obviously informs Alison Kelly, who’s the Executive lead for patient safety, as to how significant three babies dying in that short period of time was.”176
  5. Dr Brearey emailed his summary report to Ms Peacock, copying in Ms Powell and Dr Jayaram, for use at the Serious Incident Panel meeting on 2 July 2015 (see Chapter 4).177

Equipment

  1. Following the deaths of Baby A, Baby C and Baby D, Ms Powell checked the incubators, the thermometers and the antibiotics prescribed to the babies.178 Ms Powell was satisfied that each baby was nursed in a different incubator, the thermometers were in good working order and the antibiotics were given as per the electronic Medication Administration Record (eMAR) system. No issues were found.179
  2. In his Inquiry statement, Dr Brearey stated that, as part of the reviews into the three deaths, “it was important to consider contaminated TPN [total parenteral nutrition] as a possible cause”. In oral evidence, Dr Brearey explained that “only two of the babies had TPN and Baby D wasn’t on TPN at the time so that was excluded”.180
  3. The microbiology of each baby was also checked; the test results were negative.181 In oral evidence, Dr Brearey told the Inquiry: “[T]here wasn’t any microbiology evidence that there was any — any links [between the three babies].”182

Footnotes

  1. * When reviewing this death, Dr Gibbs advised a change so that, where a priest was not available, a member of staff should carry out a baptism; see INQ0000108/27.

  2. † The Apgar score is used to assess the condition of a baby at birth. It considers five factors, each scoring from 0 to 2: Appearance, Pulse, Grimace, Activity and Respiration. A score of 10 is not common. A score of 7 or above is reassuring.

Endnotes

  1. 1 Mother A and B 16 September 2024 2/16-18

  2. 2 Mother A and B 16 September 2024 10/20-23

  3. 3 Melanie Taylor 10 October 2024 18/7-10 and 12-16

  4. 4 Nurse T 14 October 2024 28/25 to 29/2

  5. 5 Melanie Taylor 10 October 2024 18/25 to 19/5

  6. 6 Nurse T 14 October 2024 29/6-18

  7. 7 Nurse T 14 October 2024 29/11-15

  8. 8 Melanie Taylor 10 October 2024 21/1

  9. 9 Melanie Taylor 10 October 2024 19/16

  10. 10 Nurse T 14 October 2024 32/8-9

  11. 11 Nurse T 14 October 2024 34/6-8

  12. 12 Mother A and B 16 September 2024 9/7-9

  13. 13 Mother A and B 16 September 2024 9/11-12

  14. 14 Mother A and B 16 September 2024 3/5-6 and 4/1-2

  15. 15 Nurse T 14 October 2024 36/11-14

  16. 16 Witness statement of Dr David Harkness INQ0102350/3/para 13

  17. 17 Nurse T 14 October 2024 30/24 to 31/2

  18. 18 Witness statement of Dr David Harkness INQ0102350/3/para 14

  19. 19 Dr Rachel Lambie 2 October 2024 8/19 to 11/10

  20. 20 Dr Ravi Jayaram 13 November 2024 21/13-16

  21. 21 Dr Ravi Jayaram 13 November 2024 21/19-20

  22. 22 INQ0001986/6

  23. 23 Mother A and B 16 September 2024 34/25 to 35/6

  24. 24 INQ0002042/4

  25. 25 Mother A and B 16 September 2024 3/5-7

  26. 26 Nurse T 14 October 2024 37/3

  27. 27 Nurse T 14 October 2024 37/13-20

  28. 28 Nurse T 14 October 2024 38/12-15

  29. 29 Nurse T 14 October 2024 39/3-4

  30. 30 Dr Rachel Lambie 2 October 2024 11/20-22

  31. 31 INQ0000698/26-28

  32. 32 Dr Rachel Lambie 2 October 2024 39/11

  33. 33 Dr Rachel Lambie 2 October 2024 12/3

  34. 34 Dr Rachel Lambie 2 October 2024 12/5-8

  35. 35 Dr Rachel Lambie 2 October 2024 14/12-13

  36. 36 Dr V 7 October 2024 89/21-23

  37. 37 INQ0000698/28

  38. 38 INQ0000698/29

  39. 39 Dr V 7 October 2024 90/5-11

  40. 40 INQ0000698/25

  41. 41 Dr V 7 October 2024 91/17-19

  42. 42 Dr Rachel Lambie 2 October 2024 11/4-13

  43. 43 Dr John Gibbs 1 October 2024 126/22 to 127/3

  44. 44 Witness statement of Dr Katherine Lyddon INQ0017996/8/para 28

  45. 45 Mother A and B 16 September 2024 35/3-5

  46. 46 Mother A and B 16 September 2024 49/15-19

  47. 47 INQ0000008

  48. 48 Yvonne Griffiths 16 October 2024 107/5-7

  49. 49 Yvonne Griffiths 16 October 2024 107/11-16

  50. 50 Yvonne Griffiths 16 October 2024 108/24-25 and 109/2-3

  51. 51 INQ0000101/1-2

  52. 52 Ashleigh Hudson 10 October 2024 83/19-25

  53. 53 Ashleigh Hudson 10 October 2024 85/17-20

  54. 54 INQ0000101/6-7

  55. 55 Melanie Taylor 10 October 2024 20/25 to 21/1-3

  56. 56 Mother A and B 16 September 2024 42/20-21

  57. 57 INQ0000008

  58. 58 Mother C 16 September 2024 61/20 to 62/1

  59. 59 Mother C 16 September 2024 57/16-25

  60. 60 Mother C 16 September 2024 60/10-11

  61. 61 Mother C 16 September 2024 59/24-25

  62. 62 Mother C 16 September 2024 60/24 to 61/11

  63. 63 Witness statement of Dr Katherine Davis INQ0018001/2/para 7

  64. 64 Witness statement of Dr Katherine Davis INQ0018001/3/para 9 to 4/para 11

  65. 65 Dr John Gibbs 1 October 2024 43/23-24

  66. 66 Witness statement of Dr Katherine Davis INQ0018001/4/para 12

  67. 67 Mother C 16 September 2024 63/5 to 64/6

  68. 68 Mother C 16 September 2024 65/5-9

  69. 69 Mother C 16 September 2024 67/5-24

  70. 70 Mother C 16 September 2024 68/3-5

  71. 71 Mother C 16 September 2024 68/9-17

  72. 72 Nurse W 14 October 2024 93/21

  73. 73 Nurse W 14 October 2024 93/13-15

  74. 74 Nurse W 14 October 2024 145/1-2; Mother C 16 September 2024 68/10-20

  75. 75 Melanie Taylor 10 October 2024 59/24-25

  76. 76 Nurse W 14 October 2024 93/4-9 and 98/3-9; Melanie Taylor 10 October 2024 29/21 to 30/17 and 59/20 to 60/1

  77. 77 Eirian Powell 17 October 2024 78/5-12

  78. 78 Eirian Powell 17 October 2024 78/19-23

  79. 79 Eirian Powell 17 October 2024 80/17-19

  80. 80 Eirian Powell 17 October 2024 79/2-3

  81. 81 Eirian Powell 17 October 2024 72/14-18; INQ0003243/1

  82. 82 Mother C 16 September 2024 69/24 to 70/5

  83. 83 Mother C 16 September 2024 69/13-17

  84. 84 Melanie Taylor 10 October 2024 60/12

  85. 85 Melanie Taylor 10 October 2024 60/16-23

  86. 86 Nurse W 14 October 2024 96/23-24

  87. 87 Dr John Gibbs 1 October 2024 209/19-21

  88. 88 Dr John Gibbs 1 October 2024 209/5

  89. 89 Witness statement of Sophie Ellis INQ0017829/4/para 14

  90. 90 Witness statement of Sophie Ellis INQ0017829/3/paras 10-13

  91. 91 Dr John Gibbs 1 October 2024 58/7-15

  92. 92 Dr John Gibbs 1 October 2024 199/16 to 201/23

  93. 93 Dr John Gibbs 1 October 2024 43/12-14

  94. 94 INQ0002047/3

  95. 95 Dr John Gibbs 1 October 2024 44/8-9

  96. 96 Dr John Gibbs 1 October 2024 208/16-20

  97. 97 Dr John Gibbs 1 October 2024 65/24 to 66/6

  98. 98 Dr John Gibbs 1 October 2024 66/11-12

  99. 99 INQ0008979/2

  100. 100 Dr John Gibbs 1 October 2024 66/23 to 67/2

  101. 101 INQ0000111/1

  102. 102 Julie Fogarty 15 October 2024 97/22 to 100/7

  103. 103 Mother C 16 September 2024 118/11-12

  104. 104 Mother C 16 September 2024 116/16-19

  105. 105 Mother D 17 September 2024 9/1-11

  106. 106 Witness statement of Caroline Oakley INQ0101334/4/para 20

  107. 107 Mother D 17 September 2024 19/2-10

  108. 108 Witness statement of Kathryn Percival-Calderbank INQ0017999/6/para 38

  109. 109 Witness statement of Dr Andrew Brunton INQ0018067/4/para 16

  110. 110 Witness statement of Caroline Oakley INQ0101334/3/para 14

  111. 111 Witness statement of Dr Emily Thomas INQ0017995/6/para 27

  112. 112 Mother D 17 September 2024 50/7-10

  113. 113 Witness statement of Dr Andrew Brunton INQ0018067/4/para 17

  114. 114 Witness statement of Dr Emily Thomas INQ0017995/7/para 31

  115. 115 Witness statement of Dr Andrew Brunton INQ0018067/4/para 16

  116. 116 Witness statement of Dr Andrew Brunton INQ0018067/4-5/paras 17-18

  117. 117 Dr Elizabeth Newby 3 October 2024 18/3-23

  118. 118 Mother D 17 September 2024 20/12-13

  119. 119 Mother D 17 September 2024 23/13-15

  120. 120 Witness statement of Caroline Oakley INQ0101334/4/para 20

  121. 121 Dr Elizabeth Newby 3 October 2024 17/8-11

  122. 122 Dr Elizabeth Newby 3 October 2024 17/12-13

  123. 123 Mother D 17 September 2024 45/5 to 46/16

  124. 124 Mother D 17 September 2024 6/10-21

  125. 125 Dr Elizabeth Newby 3 October 2024 18/2-6

  126. 126 INQ0002045/8

  127. 127 Dr Jo McPartland 12 November 2024 111/7-8

  128. 128 Dr Jo McPartland 12 November 2024 111/12-14

  129. 129 Dr Jo McPartland 12 November 2024 156/21-23

  130. 130 Dr Elizabeth Newby 3 October 2024 45/5

  131. 131 Dr Elizabeth Newby 3 October 2024 16/9-11

  132. 132 INQ0008651/2

  133. 133 INQ0008651/3

  134. 134 Mother D 17 September 2024 30/16-20

  135. 135 Dr Elizabeth Newby 3 October 2024 27/22-25

  136. 136 Nurse T 14 October 2024 42/13 to 43/6

  137. 137 Nurse T 14 October 2024 43/10-16

  138. 138 Nurse T 14 October 2024 44/4-5

  139. 139 Nurse T 14 October 2024 44/6-10

  140. 140 Eirian Powell 17 October 2024 83/21 to 84/7 and 85/13-17

  141. 141 INQ0003110/4-5

  142. 142 INQ0003110/4-5

  143. 143 Dr Stephen Brearey 19 November 2024 59/21-22

  144. 144 INQ0000766/1

  145. 145 Dr Rachel Lambie 2 October 2024 17/4-8

  146. 146 Dr Rachel Lambie 2 October 2024 16/12-20

  147. 147 Dr Elizabeth Newby 3 October 2024 22/14-16

  148. 148 INQ0025743/2

  149. 149 INQ0025743/1

  150. 150 Dr Elizabeth Newby 3 October 2024 23/10-13

  151. 151 INQ0025743

  152. 152 Dr Stephen Brearey 19 November 2024 37/21 to 38/8

  153. 153 Dr Stephen Brearey 19 November 2024 42/5-8 and 43/2-5

  154. 154 Mother A and B 16 September 2024 41/5-8

  155. 155 INQ0036166/2

  156. 156 Dr Elizabeth Newby 3 October 2024 22/18-21

  157. 157 INQ0000101/22-23

  158. 158 Nurse T 14 October 2024 48/11

  159. 159 Nurse T 14 October 2024 48/8-10

  160. 160 Nurse T 14 October 2024 33/25 to 34/23

  161. 161 Eirian Powell 17 October 2024 74/21 to 76/2

  162. 162 Eirian Powell 17 October 2024 77/3 and 77/20

  163. 163 Eirian Powell 17 October 2024 87/12-13

  164. 164 Eirian Powell 17 October 2024 76/3-11

  165. 165 Yvonne Griffiths 16 October 2024 113/20-22

  166. 166 Yvonne Griffiths 16 October 2024 114/17-19

  167. 167 Dr John Gibbs 1 October 2024 54/7 to 55/8

  168. 168 Dr John Gibbs 1 October 2024 55/10-14

  169. 169 Dr John Gibbs 1 October 2024 56/6 to 57/6

  170. 170 INQ0003191/1-6

  171. 171 INQ0026017/3

  172. 172 INQ0003191/1-3

  173. 173 Eirian Powell 17 October 2024 91/21 to 92/5

  174. 174 Dr Stephen Brearey 19 November 2024 44/13 to 45/3

  175. 175 INQ0003191/3

  176. 176 Dr Stephen Brearey 19 November 2024 45/23 to 46/2

  177. 177 INQ0008302; INQ0003191/1-6

  178. 178 INQ0003110/7

  179. 179 INQ0003110/4

  180. 180 Dr Stephen Brearey 19 November 2024 49/4-6

  181. 181 INQ0003110/6

  182. 182 Dr Stephen Brearey 19 November 2024 48/22-24

Previous
Chapter 2
The neonatal unit, 2015 to 2016
Next
Chapter 4
Risk and Patient Safety Department