Chapter 10. June 2016: Baby N, Triplets O, P and R

Baby N

Father N: “[T]he plan was that he would be delivered by caesarean section several weeks earlier than normal. We were both aware of this and the reasons for it.”¹

Despite the decision that Letby would work only on days for another two months, she worked four nights at the end of May and beginning of June. She was on the night shift of 2/3 June 2016.²
Baby N was born at 34 weeks and 4 days’ gestation, weighing 1.67 kilograms. Baby N collapsed on 3 June 2016 and twice on 15 June 2016. On the night shift of 2/3 June 2016, Baby N was in Nursery 1. Mr Booth was his designated nurse.
Mr Booth set out in his Inquiry statement a passage from the nursing notes that he made about what had happened during his break when another nurse, whom he could not remember, was looking after Baby N. He said that he had been given the information by someone, but again he could not remember who. During his break, Baby N had an episode where he was “crying ++ and not settling. He became dusky in colour, desaturating to 40’s. Responded to facial oxygen within 1–2 minutes … No further episodes occurred.”³ Mr Booth said that there was no corresponding note in the medical records. The prosecution case was that this episode, and quick recovery, was consistent with an inflicted injury caused by Letby. Letby was convicted of attempted murder in relation to the collapse on 3 June 2016.
The Countess did not tell Baby N’s parents about his collapse on 3 June 2016. Father N said:
“We now know that Child N’s oxygen saturations dropped very low overnight to 40% … The Inquiry has asked whether we were told about this deterioration at the time and how and when we were told about it. We were not told about this deterioration. We did not know Child N had had problems overnight … I find this disgusting. As parents we have an absolute right to know what was happening to and with our son.”⁴
Mother N echoed Father N’s account of being kept in the dark about Baby N’s collapse. She stated:
“I was not made aware there had been any problems with Child N’s condition in the early hours …
The Inquiry has asked me for my views on the adequacy of the information on the neonatal unit at [the hospital] … I considered the information to be inadequate, in terms of the processes on the neonatal unit, how to care for a baby there, and also information about Child N’s condition.”⁵
Two further charges of attempted murder of Baby N were brought against Letby in respect of two collapses on 15 June 2016. The jury could not agree on a verdict on either case. The prosecution case was that, on 15 June 2016, Baby N again suffered an inflicted injury, this time resulting in heavy bleeding in the throat area. Baby N had been deteriorating from 1am. The first collapse was just before the day shift began, when Letby was already on the neonatal unit, having arrived early. The second collapse was at about 2pm. Letby was his allocated nurse. The damage was such that it was difficult to intubate Baby N. Staff from Alder Hey came to assist in his intubation. Baby N was subsequently transferred to Alder Hey and survived the trauma.
Speaking about Baby N’s deterioration on 15 June 2016, Mother N told the Inquiry:
“[That] day we were called to the neonatal unit was the worst day of our lives, from waking up that morning being prepared to take home our son to the utter catastrophic scene we arrived at has left a lasting imprint on us, seeing our tiny baby fighting for his life, medics doing CPR on his tiny body and not knowing if he was going to live or die with no obvious cause.”⁶

She added: “I just kept questioning why our healthy baby boy was fine one minute and then bleeding from the mouth and needing CPR the next.”⁷

Father N’s evidence was that:
“Lucy Letby told me he had been a bit unwell in the night but did not explain what that meant or what was wrong with him. No one did. We had not received a call in the night to alert us to any problems or that anything had happened.
… when I saw Child N, I was shocked. He was blue in colour and had traces of blood around his lips like he had coughed up blood and it had splattered on him. The blood was dry and dark in colour.”⁸
Father N said that on 15 June 2016:
“A nurse came to speak to us … The nurse said that Child N was now really unwell and if we wanted we could see a priest.
Mother N went into the ITU and the priest arrived to talk to us. I was shocked by this as I am not religious and we had not asked for him … It felt really inappropriate because he was a stranger and I had the impression that we were being ushered out of the way.”⁹

Father N stated that it was Letby who recommended they get Baby N baptised, and that they ultimately did so out of desperation.¹⁰

Dr Brearey was involved in Baby N’s care on the afternoon of 15 June 2016, when he collapsed and required intubation. He and his colleagues had been discussing Baby N’s management and difficulties with intubation. In oral evidence, Dr Brearey said: “It is worthwhile saying that Child N was a morbidity case and I have said in my statement as well, that I was — I was blinded by the medical issues in the case in terms of the haemophilia that Child N had and the difficulty with the airway that was — was encountered which blinded me to the actions of Letby.”¹¹
Dr Saladi was involved in Baby N’s resuscitation on the afternoon of 15 June 2016. He agreed that Baby N’s deterioration was sudden and unexpected. However, he did not speak to Dr Brearey or Ms Powell about it, as directed by Dr Brearey’s email of 16 May 2016, because Dr Brearey was involved in the resuscitation.¹²
There is no evidence that the collapses of Baby N were escalated to Ms Kelly or Mr Harvey. They should have been.
Datix forms were not completed for Baby N’s collapses. See also Chapter 4 for more on failures to complete Datix forms. Following the deaths of Baby O and Baby P in June 2016, there was a great deal going on, but Dr Brearey accepted that he should have looked at Baby N’s care in more depth at the time and apologised for this.¹³ Baby N’s case was added by Ms Powell to her Additional Monitoring Report.¹⁴
Father N spoke candidly about visiting Baby N on the neonatal unit and being “a bit scared to go there alone as he was so small and vulnerable”. He recounted that “when Child N was about 10 days old Lucy Letby said to me ‘Hold him! He is your son’. She was very abrupt and short with me. I did not say anything in reply. Child N was just lying happily in his cot and he was settled and not crying. She did not hand him to me and I did not pick him up.”¹⁵
Parents N were not informed of any reviews into Baby N’s collapse. Mother N said: “Once Child N had left the care of [the hospital], we did not hear anything from the hospital about the causes of the collapses or any investigation into them.”¹⁶ Mother N told the Inquiry that, when Baby N was a few months old, Parents N attended an appointment with Dr Saladi. Mother N described Dr Saladi as “unable to give a reason for why the collapses had occurred” and that “it seemed that Dr Saladi did not have any answers”.¹⁷ Dr Saladi recalled that he had a meeting with Parents N, in which he informed them that he was not able to give them a reason for the collapse, and that he did not have answers.¹⁸ They were not told about any investigations that were being carried out.¹⁹

Messages between Dr U and Letby

Dr U informed the Inquiry that he began Facebook messaging Letby in June 2016.²⁰ The Inquiry are aware of approximately 1,355 messages they exchanged between June and September 2016. Dr U acknowledged that this was a large volume of messages.²¹ Dr U was invited to explain why the pair messaged to that extent. He replied:
“Letby was struggling with her mental health and I think I picked up on that and I’d offered some support, and that support, it grew, and I understand that she slept very poorly because of worry and anxiety, and there were often messages that were passed throughout the day and sometimes late at night, earlier in the morning.”²²
Dr U was the night-shift registrar on 14/15 June 2016. Letby worked the day shift on 15 June. Dr U and Letby were both involved in Baby N’s care. Dr U acknowledged that he and Letby “passed several messages” during 14 and 15 June.²³ The messages included personal topics and matters relating to Baby N, including his deterioration and intubation attempt at around 7.15am (which both Dr U and Letby were involved in).²⁴
The following is an excerpt from the transcript of Dr U’s evidence:
“Ms Langdale KC: Do you think it was appropriate to be messaging about Baby N with her at this time?
Dr U: In hindsight, no.
Ms Langdale KC: Why not?
Dr U: Looking at the content of the messages here, I’ve shared too much, and from my reflections since this has happened, it’s common to give updates on how patients are without naming them, without giving lots of clinical detail to help the recipient understand where that patient is up to. I gave, at the time, details that I thought were helpful but I see now that that probably wasn’t the case.
Ms Langdale KC: And how do you think Baby N’s parents would feel about that?
Dr U: I’m sure that’s very upsetting.
…
Ms Langdale KC: And within those messages, it [flits] from information about the child to quite frivolous, casual conversation in the way that friends do, doesn’t it?
Dr U: It does.
Ms Langdale KC: Entirely inappropriate to have somebody’s baby in the centre of that communication after such a serious deterioration and now we know an attack —
Dr U: Yes.”²⁵
When Mother N learnt about the messages that Dr U and Letby shared, she “lodged a complaint against Doctor U”.²⁶ She explained:
“I made this complaint when it was revealed at the criminal trial that he had discussed Child N with Lucy Letby on Facebook and by private text message, even referring to Child N by their surname. There were several grounds to my complaint. One was his disregard for, and blatant breaches of, patient confidentiality. In addition, he shared emails that had been exchanged between Consultants in regard to Lucy Letby’s conduct with her, and should not have done that … I raised the complaint with PALS.”²⁷
On 16 June 2016, the Women and Children’s Care Governance Board met. The Thematic Review had been received by the meeting. It is not clear whether this was the February 2016 version or, as it should have been, the March 2016 version. In attendance were Ms Fogarty, Dr Davies, Ms Lawrence, Dr Jayaram, Ms Anne Murphy and others. The minutes read: “There was no common theme identified in all the cases.”²⁸ This was a direct quotation from the Thematic Review.²⁹ There was no discussion. By that stage, the ‘monitor and alert’ approach, which is effectively ‘wait and see’, had been in place for a month.

Baby O, Baby P and Baby R

Father O, P and R: “I remember the day we found out we were having triplets really clearly. It was at the 12-week scan and while the sonographer was checking the imaging I was sure I could see two heads on the screen. I told Mother O, P and R what I could see and she thought I was being silly, but the sonographer replied that she thought that there were more than two. We then found out there were three babies.”³⁰

“We were so shocked that Mother O, P and R burst into tears; partly from surprise/excitement and partly because it suddenly hit us both that we would need to find a way to … support three babies as well as ourselves and our oldest child. It felt like a once in a lifetime opportunity to welcome three children at once. I felt really blessed in that moment.”³¹

Mother O, P and R received her antenatal care at the Countess. Dr McCormack was her consultant. In the weeks running up to the birth of their babies, the parents were told that the chances of giving birth at the Countess were “quite slim” as staff thought it unlikely they would have enough beds and nurses available to care for them.³² Mother O, P and R told the Inquiry: “I was warned by Consultants that it was likely that we would have to travel to another hospital. We were told that this could be Birmingham or London but we had to be ready to go anywhere.”³³ However, when she went into labour, she “was told that there were enough nurses and beds to deliver the babies [at the Countess]”.³⁴ Father O, P and R described the conditions of the operating theatre in his evidence. He recalled being “struck” by “how cold looking and dingy the room felt”.³⁵ He added: “[I]t didn’t fill me with confidence. The state of the theatre was like something out of a horror film; when I walked in there I immediately felt uneasy. It was very cold and unhygienic.”³⁶
Unfortunately, Dr McCormack was on leave when Baby O, Baby P and Baby R were to be born, and they were delivered by a doctor their parents did not know.³⁷ All three babies were delivered quickly by caesarean section. Mother O, P and R felt rushed, and experienced some pain during the delivery for which she required medication, but all three babies were born in good condition. Baby O, Baby P and Baby R were born at 33 weeks and 2 days’ gestation. Baby O weighed 2.020 kilograms and Baby P weighed 2.066 kilograms. Baby R weighed 1.865 kilograms.
Dr McCormack told the Inquiry that the triplets were born “in excellent condition”.³⁸ Mother O, P and R told the Inquiry: “Father O, P and R was asking the nurses if the babies had come out fine, and if their weights were okay. We were reassured that their weights were better than expected and that they had been born healthy.”³⁹
Around this time, Dr U and Letby were messaging regularly, and some of the messages were about the triplets. On 22 June 2016, the day Letby returned from a holiday abroad, and the day before the death of Baby O, Letby asked Dr U: “What gestation are the trips?”⁴⁰ Dr U said in evidence that he thought Letby was asking for information about the triplets in preparation for returning to work, as she had recently been on holiday.⁴¹

Baby O

Ms Taylor worked the day shift on 23 June 2016. She told the Inquiry that Baby O was initially in Nursery 1. Letby was Baby O’s designated nurse on the day shift.⁴² Baby O was later moved to Nursery 2 to be with his brothers. In Nursery 2, Ms Taylor felt uneasy (she described it as a ‘gut feeling’) about his condition and suggested to Letby that they should move him to Nursery 1. Ms Taylor explained that Nursery 1 had more emergency equipment accessible if a child deteriorated. However, Letby said she wanted him to stay in Nursery 2.⁴³
Dr Brearey was on the neonatal unit and was asked by Dr U for assistance in intubating Baby O. Dr Brearey described the intubation as uneventful but noted a purpuric rash on Baby O’s chest.
Mother O, P and R described Dr U and Father O, P and R coming to her bedside at around 3pm on 23 June 2016. Dr U informed them that Baby O needed extra breathing support, but he told her that was not uncommon for babies on the unit. Mother O, P and R wished to see Baby O for herself and went down to the neonatal unit. In fact, Baby O had deteriorated, and was moved to Nursery 1. His mother described being confronted with “complete chaos” and that the healthcare staff were running around doing everything they could to help Baby O.⁴⁴ She stated that Dr U looked panicked and did not know what was going on. She commented: “It was clear that Child O’s collapse was a complete shock to them.”⁴⁵
Because Baby O was suffering an “unusual and unexpected event” with an “unknown cause”, the neonatal unit contacted Dr Oliver Rackham, a consultant paediatrician on the neonatal intensive care unit at Arrowe Park Hospital, and a consultant on the neonatal transport team which serves Cheshire and Merseyside.⁴⁶ The intention was to take Baby O from the Countess and transfer him to an intensive care unit. Very sadly, Baby O died before this could happen.⁴⁷ Dr Rackham commented on the gestational age of Baby O, Baby P and Baby R (33 weeks and 2 days) and stated “babies of that gestation are normally relatively well … those babies in general we would expect to do well and survive”.⁴⁸
Dr Brearey assisted with the resuscitation of Baby O. He did not see Letby do anything untoward. In evidence, he said he was “exceedingly worried” after Baby O died.⁴⁹ He had noted the rash earlier, and connected this to the rashes that had been observed on babies in June 2015 (on Baby A, Baby B and Baby D). He considered this unusual. Father O, P and R described Baby O’s rash as follows: “His skin was a different colour and it looked almost like there was something pulsating through his veins.”⁵⁰ He also described swelling on Baby O’s abdomen and that “his stomach had popped out almost like a pot belly”.⁵¹
Father O, P and R commented: “The doctors seemed as baffled as we were, and no one could tell us why things had suddenly gone so wrong. It was really shocking. I have no medical training and it felt like the doctors were essentially in the same boat as me.”⁵²
When Baby O died at 17:47, Mother O, P and R told the Inquiry: “No one seemed to know how this had happened. Everyone was in shock and disbelief.”⁵³
Letby was convicted of Baby O’s murder.
Dr Huw Mayberry, a registrar, had cared for Baby O on the night shift of 22/23 June 2016. He said Baby O had a mildly distended stomach. However, this is a common finding in a child on high-flow nasal cannula oxygen and he “wasn’t particularly concerned about him”.⁵⁴ When Dr Mayberry returned to work on 23 June 2016, he learnt that Baby O had died earlier that day. He told the Inquiry he was “shocked because nothing seemed unusual on that nightshift”.⁵⁵
This was a death that shocked all those on duty. In evidence, Ms Taylor told the Inquiry that there were “no clinical recordable signs that I could have said this baby is deteriorating. So his observations, such as his heart rate, breathing, stayed the same or stable as he was previously.”⁵⁶
Ms Bennion’s written evidence was similar:
“I was personally alarmed or alerted to the number of child deaths when one of the triplets died … It was completely unexpected, they were mature babies born at 33 weeks, good weights and although they were receiving respiratory support, they were very stable. I wondered if there was a significant infection on the unit that we were missing.”⁵⁷

There was no such infection, as I explain in Chapter 11.

Dr Brearey also said that, although Baby O’s resuscitation was well performed, Baby O did not recover.⁵⁸ Dr Brearey confirmed that, after Baby O’s death, he intended to raise concerns with Ms Powell and escalate them to the executives that same day. Ultimately, however, he did not escalate his concerns to anyone senior that day, because it was early evening and senior people had left the hospital. He reflected: “I regret waiting until the following day to act. It would have been far more appropriate to trigger something on that Thursday evening rather than wait to the following morning.”⁵⁹ I agree, although what would have happened is far from certain, given what did happen the following day.
Ms Griffiths was referred to Dr Brearey’s comment in his Inquiry statement that he could not conceive how Letby had been allowed to work on the neonatal unit the day after Baby O died.⁶⁰ She knew, as she accepted, that Dr Brearey was concerned about Letby. She was responsible for managing the rota. Her view was that, if somebody had directly approached her with concerns that Letby should not work with nor care for the surviving triplets, then she would have reallocated her.⁶¹ This is not an acceptable answer for two reasons. First, Ms Griffiths, despite her shifting evidence about Baby I, accepted that, by the time of the deaths of Baby O and Baby P, she knew about Dr Brearey’s concerns. She even commented on the look on his face.⁶² She inferred at the time of the resuscitation that Dr Brearey was worried that Letby was involved. She did not have to wait for Dr Brearey to tell her again. She knew it. She had personal responsibility for safeguarding (see Chapter 12). The fact that others had the same responsibility did not remove hers. Second, she seems to have given no consideration to the wisdom of putting someone back in charge of surviving triplets when she had been part of a failed resuscitation just the evening before.
After Baby O’s death, Dr U and Letby exchanged messages about the resuscitation and debrief. At 22:07 on 23 June 2016, Dr U messaged Letby: “I think the debrief was good – we didn’t come up with anything missed or delayed.”⁶³

Baby P

Baby P collapsed on the morning of Friday 24 June 2016. He received adrenaline and CPR and seemed to have improved, but he collapsed again in the afternoon when he was about to be transferred to Liverpool Women’s Hospital. He deteriorated despite resuscitation and died. Letby was convicted of his murder.
Mother O, P and R stated that, on 24 June 2016, she was very worried for her surviving sons, Baby P and Baby R. She recalled that she went down to the neonatal unit at around 6am and “was told by the nurse that the boys were ‘little angels’ and that she had no concerns”.⁶⁴ She later found out at the criminal trial that Baby P had been unwell in the night. Mother O, P and R went back to the maternity ward. Later, a nurse ran into her room and told her that Baby P was really poorly and she needed to go down to the unit right away. Mother O, P and R told the Inquiry that, when she got to the unit, she was confronted with the same panic as the day before. She stated that, while Baby P was being resuscitated, “I felt entirely forgotten and ignored”.⁶⁵
Father O, P and R said that, when he and his dad arrived on the neonatal unit:
“It was almost an exact repeat of the day before.
Everyone was running around like headless chickens looking like they had no idea what was wrong. I asked one of the doctors what was going on and said ‘it’s happening again, isn’t it’. Nothing was said to me; no one could explain it, again.
They couldn’t tell me what was happening.”⁶⁶
Father O, P and R observed: “Child P had the same mottling on his skin, the same distension on his belly [as Baby O] and I just knew it was the same thing, even though I didn’t know what that thing was.”⁶⁷
After contact from the Countess during the course of the day, the plan was to transfer Baby P to the neonatal intensive care unit at Liverpool Women’s Hospital. Dr Rackham had made arrangements for a cot space to be made available, and travelled to the Countess with the intention of transferring Baby P. Baby P collapsed shortly after Dr Rackham arrived, and Dr Rackham led the unsuccessful resuscitation. Dr Rackham affirmed what he wrote in his statement to the Inquiry, that “there was no identifiable cause of death at that time, so I was surprised at the collapse and the death and unable to explain what happened”.⁶⁸ Mother O, P and R told the Inquiry that Dr Rackham “said that he didn’t know what had happened and could not believe what was happening, but that he could not do anything else for Child P”.⁶⁹ Mother O, P and R recalled:
“Father O, P and R begged Dr Rackham to take Child R to Liverpool Women’s Hospital … Father O, P and R and I did not know what was wrong at this point but I just knew we needed to get Child R out of the Countess of Chester Hospital. I didn’t think anything malicious had happened at the time, but I did feel that something had gone wrong in the Unit.”⁷⁰

Father O, P and R also had similar concerns that something was not right.⁷¹

Dr V was involved in Baby P’s care. She informed the Inquiry that, prior to Baby P’s collapse, he had appeared stable and reasonably well. She considered that his deterioration was very unexpected.⁷² She recalled “begging in my head” for Dr Rackham to take Baby R, because she feared that he would die next.⁷³
Dr Rackham told the Inquiry that the thought of deliberate harm was not in his mind after Baby O’s and Baby P’s deaths, and no one had mentioned concerns about Letby to him.⁷⁴ There were no medical concerns regarding Baby R, but he agreed to transfer Baby R to Liverpool Women’s Hospital out of caution, because of the deaths of Baby O and Baby P. He explained his rationale: “The child was well but was a triplet and the other two triplets had died without any explanation … in case there was some underlying condition in that family, such that that baby was also going to have a collapse, it would be more sensible for him to be in an intensive care unit when that happened.”⁷⁵ The post-mortem reports made no reference to any underlying conditions, nor did the mortality reviews of either Baby O or Baby P. Baby R thrived in Liverpool Women’s Hospital and remained well.
At the close of Dr Rackham’s oral evidence, Parents O, P and R, via their counsel, expressed their view that Dr Rackham’s actions had saved Baby R’s life. For this they expressed their “profound gratitude” to Dr Rackham.⁷⁶
Dr Mayberry worked the night shift of 23/24 June 2016. He told the Inquiry that he received a call from a nurse that there was concern that milk had been aspirated from Baby P’s nasogastric tube. He described this as a relatively common occurrence and that “there was no other concern about Child P at the time”.⁷⁷ In his statement to the Inquiry, Dr Mayberry wrote that he was “devastated, shocked and bewildered” to learn that Baby P had died when he arrived for his night shift of 24/25 June 2016.⁷⁸
Ms Percival-Calderbank told the Inquiry that she was “stunned” to learn that Baby P died.⁷⁹ She stated that, prior to their deaths, both Baby O and Baby P had been generally well. Ms Percival-Calderbank was not aware of any discussions of an unnatural cause of death, or Letby’s involvement in the deaths of Baby O and Baby P. However, she stated that she had a “niggle” or a “concern” about the deaths being untoward.⁸⁰

Letby’s response to the deaths of Baby O and Baby P

Dr V told the Inquiry that, up until Baby O’s and Baby P’s deaths, she did not have concerns that the deaths on the neonatal unit were unnatural. However, she had “overheard remarks being made about how when Lucy was around — around things were happening, and it was more so not being able to quantify, well, is it because she’s unlucky that she has shifts which has really sick babies and things happen?”⁸¹ Dr V told the Inquiry that Baby P required resuscitating twice on 24 June 2016. She said that, after his first resuscitation, Letby commented: “He’s not leaving here alive, is he?”⁸² Dr V said she was in “disbelief” and had never heard a healthcare professional make that type of remark.⁸³ She informed Ms Powell of Letby’s comment at a meeting on 27 June 2016.⁸⁴
Ms Powell recalled Dr V informing her that Letby had made an “inappropriate comment”; however, she said Dr V could not remember the details of it.⁸⁵ Ms Powell did not take steps to find Dr V and ask further questions about the comment.⁸⁶ When invited to give her view on the alleged comment, Ms Powell stated: “It’s totally unacceptable.”⁸⁷
It is highly unlikely that Dr V would report an inappropriate comment made on 24 June 2016 without being able to remember the details of it on 27 June 2016. She remembered them at the Inquiry, eight years later. It is not a complex utterance. I accept that she told Ms Powell that Letby had said: “He’s not leaving here alive, is he?” I find that Ms Powell did not mention this callous remark to anyone else. Given that she was well aware of the concerns being raised about Letby, she should have informed Ms Rees or Ms Kelly. It was another example of Letby’s disturbing comments and behaviour towards the death of babies she was caring for.
Ms Lightfoot was Deputy Ward Manager, Children’s Unit, at the Countess. She told the Inquiry that, following Baby P’s death, she was coming out of the break room and heard Letby greet a member of the night staff who was coming on duty with “something along the lines of, ‘You[’ll] never guess what just happened’”.⁸⁸ Ms Lightfoot said: “I felt it was inappropriate”,⁸⁹ and that Letby spoke of the death as if it was an “exciting event”.⁹⁰ Ms Lightfoot stated: “I have never, and I have never since seen a response like that to a nurse involved in a patient’s passing.”⁹¹ This is a further example of disturbing behaviour which echoes Letby’s enjoyment of dealing with arrangements for babies after death, taking pleasure from talking about her involvement in resuscitation. No one said anything at the time, other than that it was odd.
Ms Lightfoot said, after Baby P died, there was a moment where she perhaps thought something significant was happening, because it “seemed unusual to have two deaths in two days”.⁹² She reflected: “[I]n hindsight, you know, perhaps I — I could have escalated it but I — there was nothing substantiated. There was just an inappropriate response and I didn’t have the full awareness of what had been happening on the unit and their mortality rate for me to put two and two together.”⁹³
Nurse ZC was a children’s nurse (band 5). In the week Baby O and Baby P died, she was working on the children’s ward when the doctor’s crash bleep went off for the neonates.⁹⁴ She confirmed in her oral evidence that: “The link for me was following the event of the death of the triplets that made me concerned. This was potentially more than an experienced nurse always being allocated the unwell babies.”⁹⁵ She also told the Inquiry her concerns arose on “the second day [24 June 2016] and realising that actually she was on — had chosen to look after those babies again”.⁹⁶ I remind myself that Baby O and Baby P were good weights for triplets at 33 weeks, and they were not “unwell babies”.
Nurse ZC explained that most nurses who have suffered a death find the experience mentally and physically exhausting: “So for me to go back the next day on shift, if — you know, if it was me going back on shift, I would want the lowest acuity patient. So, for me, I found it quite strange that she chose to go back.”⁹⁷ Taking account of the fact that people are different, this was at least consistent with Letby’s preference not to be in the nurseries looking after the special care babies (see Chapter 5) because it was boring, and to prefer the drama of deterioration, resuscitation, death, and how to deal with it. I note in particular her behaviour post-death in respect of Baby C, Baby E and then, while he was still alive, Baby P. Only in retrospect was this behaviour considered all together.
In evidence, Ms Lightfoot was asked about Nurse ZC’s evidence that she had raised the link between Letby and the deaths of babies on the unit, and had been ignored. Ms Lightfoot said: “That is not the first time that I have heard Nurse ZC comment about Lucy. I had heard her and a couple of medical colleagues on a number of occasions discussing that Lucy must be involved. I felt it was quite malicious, it was gossip. It was, at that point as far as I was aware, unsubstantiated.”⁹⁸ When, after the death of Baby P, Dr Barrett said to her, “I see Nurse Death’s on again”,⁹⁹ Ms Lightfoot dismissed it on the grounds that Dr Barrett and Nurse ZC were friends, and so “I didn’t feel they were independent concerns”.¹⁰⁰ Ms Lightfoot said that, if she had been approached with a professional concern about Letby, then she would have escalated it appropriately.¹⁰¹ I infer from that that Ms Lightfoot did not think that Letby’s excitement at the death of a baby led to a professional concern.
Dr Barrett gave evidence to the Inquiry. She was clearly mortified by what she had said about Letby in June 2016. She said that, although she had noted the fact that Letby was there at a couple of the unexplained collapses and child deaths, and commented on it, it never crossed her mind that Letby was responsible for the deaths.¹⁰² I accept her explanation. Almost no one thought it possible that a nurse was harming babies. The deeply held belief that no nurse, particularly one you know, would deliberately harm babies was impossible to shift.
Nurse ZC gave evidence that, after Baby O’s and Baby P’s deaths, there were safety huddles during which staff were informed by management that there was a potential infection on the unit, and that “disciplinary measures would be considered if you were found talking about” Letby’s association with the deaths.¹⁰³ Nurse ZC recalled Ms Anne Murphy being present, but could not recall which manager had delivered the message.¹⁰⁴ In the event, as Dr Saladi said, there was no infection on the unit at all, still less one that could explain the deaths. There had been two periods of concern about infections on the unit – in 2012 and 2015, pseudomonas was found on the taps, and was dealt with and had no consequences for babies.¹⁰⁵ In February 2016, it was thought that there was an RSV outbreak on the unit. This turned out to be a false alarm.¹⁰⁶
After Baby P died, Dr V spoke to Parents O, P and R. Letby accompanied her. Dr V said in evidence that Letby asked Parents O, P and R if they would like her to make them a memory box for Baby P, in a manner that was “very inappropriate”.¹⁰⁷ Dr V was invited to expand on why it was inappropriate. She explained: “[I]t was the inappropriate jolliness, brightness to it … my experience of previously doing this with other nurses is it can be done in a calm, peaceful, reassuring manner, but not in the manner that she did.”¹⁰⁸ Father O, P and R recalled that Letby dressed Baby P. He stated Letby made a “big deal about taking photos of the boys and making memory boxes”.¹⁰⁹ This is further evidence of her apparent enjoyment of the drama and ritual around death.
Letby sent Dr U a running commentary on her actions. For example, at 18:34 on 24 June 2016, she texted: “Just going to dress him & [t]ake footprints. Hope you are ok.”¹¹⁰
Post-mortems took place in respect of Baby O and Baby P on 28 June 2016, and a subsequent secondary obstetric review of Mother O, P and R was completed on 20 July 2016. Baby O’s recorded cause of death at post-mortem was ‘1a. Haemorrhage to peritoneal space’, ‘1b. Rupture of subcapsular haematoma’, ‘1c. Prematurity’. Baby P’s recorded cause of death at post-mortem was ‘1a. Prematurity’.¹¹¹ The deaths of Baby O and Baby P were reported to StEIS.
On 29 June 2016, Ms Powell created Datix forms for Baby O’s and Baby P’s deaths. On both forms, Ms Powell listed Letby as the sole employee involved.¹¹² She explained that she did this because Letby was the designated nurse for Baby O and Baby P.¹¹³
On 30 June 2016, Letby completed a Datix form about Baby P, to the effect that there had been no sodium bicarbonate available (other than drug resuscitation boxes which were already in use). This had nothing to do with his death.¹¹⁴
Father O, P and R told the Inquiry: “[W]e had never seen the Datix reports [of Baby O and Baby P] before the trial. I didn’t even know they existed until the trial.”¹¹⁵
In her evidence, Mother O, P and R talked about the lack of information that she and the babies’ father were given about Baby O’s and Baby P’s deaths. She said:
“The information sharing with us was not adequate. It was worse than that – it was basically non-existent. Everything I have since found out about what really happened I have learned through the police, through the trial and through my solicitors. Within the NHS there is supposed to be a duty of candour. Nobody at the Countess of Chester Hospital was candid with us.”¹¹⁶
She added:
“I do not believe that the Countess of Chester Hospital were honest with us at any stage. In my view, they never should have taken on our care in the first place. We were not made aware of the higher mortality rate in the Neonatal Unit – which we now know they were aware of at that stage. I think as parents we should have been informed of this.
They knew that something untoward was going on and continued to take on my care, even though we could have been sent to a Neonatal Unit elsewhere.”¹¹⁷
The first time that Parents O, P and R learnt about the suspicions that Baby O and Baby P had been murdered was in July 2018 via a family liaison officer. Mother O, P and R stated that Father O, P and R “got the call before we saw it on the news”.¹¹⁸ She described feeling “devastated and in a state of disbelief because Lucy Letby was the one who was looking after the boys … It was Lucy Letby’s idea to take photos of the boys. She dressed them and then took photos of them together. I was never told anything about Letby by the Countess of Chester Hospital.”¹¹⁹

Bereavement support

Even though two of their babies had died at the Countess, Mother O, P and R informed the Inquiry that she and her husband “were not offered any support or counselling by the Countess of Chester Hospital. The possibility of support was never even mentioned. The first time we were offered support was through Homicide Support and then at the criminal trial.”¹²⁰
The absence of any support in these circumstances was inexcusable.