Dr Jayaram raises concerns with Ms Townsend, 24 June 2016
- In his capacity as Lead Clinician for Children’s Services, Dr Jayaram regularly met Ms Townsend. He explained that, at some point before Baby O’s death, he had arranged to meet Ms Townsend.1 They met on 24 June 2016. By the time they met, he had learnt that Baby O had died. He had been working in Liverpool on 23 June 2016.
- Dr Jayaram said in evidence that he wished to discuss several issues about the department with Ms Townsend, including his concerns about Letby. He explained he wanted Ms Townsend’s “help and support” because the consultants were not comfortable with Mr Harvey’s and Ms Kelly’s ‘monitor and alert’ approach.2
- Dr Jayaram told the Inquiry that in the meeting he said to Ms Townsend: “I stated that as a group of Consultants we were concerned, extremely concerned, about these events and we were all at a point as a group where we felt that natural causes had been excluded as far as they could be and we were really concerned about her [Letby] being on the unit.”3
- Ms Townsend’s evidence was that she met Dr Jayaram in a coffee shop on the hospital premises, by agreement, at approximately 11am on Friday 24 June 2016.4 She thought the location was an “unusual forum” for Dr Jayaram to raise his concerns, and she was “shocked” to hear them.5 She said that she had met Dr Jayaram on a couple of occasions between September 2015 and 24 June 2016, and he had not raised his concerns.6
- Ms Townsend’s notes of the meeting are: “24/6/16 RJ/KT [Dr Jayaram/Ms Townsend] … NNU [neonatal unit] triplets (1 dec’d? 2nd) concerns?”7 Ms Townsend confirmed that this was a reference to Dr Jayaram discussing Baby O’s death, and that he had concerns about Baby P.8 She stated that Dr Jayaram told her that “himself and Dr Brearey and potentially others [were] concerned around the individual being on the unit”.9
- Ms Townsend said in evidence that Dr Jayaram referred to a “drawer of doom” in which Dr Brearey had clinical evidence related to their concerns.10 She told the Inquiry that, hearing these concerns for the first time, her immediate concern was to speak to someone to see if any action needed to be taken prior to the weekend. She told the Inquiry: “[T]he risk was that there was going to be further harm to babies on the neonatal unit.”11 That was a clear description of the obvious risk that required action.
- Ms Rees was junior to Ms Townsend in the management structure, but Ms Townsend decided to speak to her about Dr Jayaram’s concerns. She told the Inquiry she did this because she did not have a clinical background, and she wanted to obtain “support and advice and kind of ask her what should we do in terms of those immediate next steps”.12 She conceded that, on reflection, approaching Ms Rees was a move down the hierarchy rather than an escalation.13 No reflection was needed. She knew Ms Rees was junior to her. If she thought it appropriate to go to a nurse, she should have gone to someone more senior. There was no reason not to go to Ms Kelly. When asked why she did not choose to escalate the concerns directly to the executives, Ms Townsend responded that she did not because of her “naivety” in her role.14 This was a major error of judgement in light of the seriousness of the situation and the seniority of her position. Ms Rees had no relevant clinical experience. Ms Townsend should have escalated the matter directly to the executives.
- In oral evidence, Ms Rees recalled that Ms Townsend bleeped her on Friday 24 June 2016. She thought it was early to mid-afternoon when she spoke to Ms Townsend in her office.15 It is likely that it was earlier than that, as I explain below.
- Ms Rees confirmed she was told that Dr Jayaram and Dr Brearey both thought Letby was “purposefully harming babies”.16 Ms Rees stated she was “horrified” to hear this, “particularly when there was no forthcoming rationale to support these allegations”.17 Ms Rees told the Inquiry: “I informed Karen Townsend that I needed to go and find both Ravi Jayaram and Steve Brearey to ascertain what exactly did they mean.”18
- It had been Ms Rees to whom Ms Kelly had turned in early May 2016, when she first reacted with shock to the email about the “staff trend” revealed in the documents forwarded by Ms Powell.19 Ms Rees had met Ms Powell, at Ms Kelly’s request, on 5 May 2016 to discuss the issue. She was party to the documents that had been produced.20 The fact of the doctors’ concerns cannot have been a surprise to her. There was no real point in her going to see the doctors. She had no relevant clinical expertise. Their concerns were clear. What was needed was immediate action to protect babies. She should have focused on that, rather than confronting the doctors.
- Dr Jayaram told the Inquiry he was in his office when Ms Rees came to see him. His summary of their conversation was as follows: “Karen Townsend had told her that myself and Dr Brearey thought that Letby was deliberately harming babies and wanted her moved from the unit and she said to me: I can’t do that without evidence, give me some evidence.”21 Dr Jayaram directed Ms Rees to speak to Dr Brearey if she wanted specific evidence.22
- Dr Jayaram spoke reflectively about his interactions with Ms Townsend and Ms Rees:
“[M]y request really of Karen Townsend and Karen Rees was to sort of say: look, we are really worried about this, we are not as a group reassured that keeping her working unsupervised is safe. Please do something.
I could have been more forthright. I could have said specifically, ‘You must remove her from the unit’ and I didn’t say that.”23
Whilst there are a number of criticisms to be made of Dr Jayaram, I do not think this is one of them. Ms Rees knew what Dr Brearey and Dr Jayaram wanted.
- Ms Rees’s recollection of her conversation with Dr Jayaram was that he told her: “Steve Brearey and I have got concerns about the clinical practice of a nurse.”24 Ms Rees told Dr Jayaram that he needed to give her more information. He did not, so she went to speak to Dr Brearey. I cannot accept that Ms Rees, knowing that Ms Townsend had told her that Dr Jayaram and Dr Brearey thought that Letby was deliberately harming babies, would have let Dr Jayaram get away with saying that he had concerns about the clinical practice of a nurse. I am satisfied that she left that meeting, as she had gone into it, knowing that the doctors thought Letby may be deliberately harming babies.
- There is a factual dispute between Ms Rees and Dr Brearey as to what time their conversation took place on 24 June 2016. I do not need to resolve the dispute. Ms Rees’s recollection of her conversation with Dr Brearey was as follows:
“Steve Brearey’s clinic had overrun so he was still in clinic in the Women’s and Children’s building and so I made my way over there and sat outside his clinic until he had finished his clinic.
When he came out I said: I need to discuss something important with you, but clearly not in this environment, so we went back to his office.
Ravi Jayaram had left, he wasn’t in the office. So I said to Steve Brearey, I said: look, I said you need to share with me why you have got these concerns and why and how do you think that she’s purposefully harming babies and his answer to me and I remember it clearly because he says: I have got a gut feeling and I have got a drawer of doom, and he pointed to a drawer in his desk so I said to him: well, share the contents of that drawer of doom with me, of which he refused. And he just said: she needs to be moved off the neonatal unit, I am aware that she is on this weekend.
So I said to him: I can’t remove a nurse from a clinical practice just because of gut feeling and a drawer of doom of which contents you will not share.”25
- This was a regrettable reaction. Ms Rees was a relatively senior nurse; she knew that babies were dying unexpectedly on the neonatal unit. She knew that the number of deaths was significantly higher than in previous years. She knew well before this meeting that the doctors were worried. She did not need experience of neonates to know that she should act to keep babies safe.
- Dr Brearey’s recollection was that, in the morning and early afternoon of 24 June 2016, he was in his clinic performing echocardiograms when one of the junior doctors asked him to perform an urgent echocardiogram on Baby P. In a supplementary Inquiry statement, dated 4 November 2024, Dr Brearey informed the Inquiry that the last scan he performed in his clinic was at 13:19, and the image was stored at 13:23. Dr Brearey then went to the neonatal unit and performed an echocardiogram on Baby P; this scan is recorded as starting at 13:30. Dr Brearey’s evidence was that the seven-minute interval – in which he closed the scanner down, packed up his notes, walked to the neonatal unit, rebooted the scanner and received a handover on Baby P – meant it was inconceivable that, between finishing the scan in the clinic and walking to the neonatal unit to scan Baby P, he and Ms Rees had a conversation in his office.26 I accept his evidence about that. I bear in mind Ms Rees’s confusion about who she spoke to the following day, believing it was Ms Powell when in fact it was Ms Farmer, as she said in evidence. Even at the time of the grievance hearing in November 2016, she said that she had spoken that day to Ms Powell when she had not. It suggests that Ms Rees’s memory of some of these events is not entirely reliable.
- Dr Brearey did say that he could recall commenting to someone that he had a “drawer of doom”27 (and I remind myself that Ms Townsend said Dr Jayaram used the same expression to her). It is likely that it was to Ms Rees that he said it that day, since she then repeated it. He said: “I can vaguely remember [the conversation] was with somebody who was standing in the doorway.”28 This seems likely to have been Ms Rees. It took place in a hurry in a doorway as Dr Brearey was in the middle of clinical duties, preparing to go to the neonatal unit to care for Baby P.
- Dr Brearey told the Inquiry the “drawer of doom” was where he kept his medico-legal files, documents related to inquests and reports of babies that died. He said he highlighted the drawer because it was rarely used. However, during the indictment period, it was getting full. It was his opinion that the way the phrase ‘drawer of doom’ was used from that point onwards was “belittling the concerns that we had and distracting from the concerns”.29 I agree with this assessment but, in fairness to those who did so, it was Dr Brearey who gave those records that name.
- Ms Rees said in evidence that, after speaking to Dr Brearey, she spoke to Ms Kelly and relayed the events of that afternoon. She stated Ms Kelly told her to speak to Mr Harvey; however, he was not in the office. She confirmed that Ms Kelly told her she was going to contact Mr Harvey.30 Mr Harvey does not remember being spoken to that afternoon.31 I do not think it makes much difference whether he was or he was not. Nor does the precise time when Ms Rees spoke to Ms Kelly matter very much either. Baby P died at 16:00, but I do not think that anything being done by the managers at that time would have made any difference to that dreadful outcome.
- Ms Kelly told the Inquiry: “[T]hat Friday afternoon, Karen Rees did come to speak to me very concerned about what she had been told from the doctors.”32 She confirmed that Dr Brearey and Dr Jayaram were concerned that Letby was intentionally harming babies, and that the trigger was Baby O’s death the previous day.33 She described what the consultants told Ms Rees as a “serious concern”.34
- Having described what the consultants had said was a serious concern, Ms Kelly sought to stress that Dr Brearey and Dr Jayaram had not directly said they were concerned that Letby was murdering babies. She stated: “That was the problem. There was no clear articulation of the facts and how that was — how they were coming to that conclusion.”35
- In the course of her evidence, Ms Kelly repeatedly said that the doctors had not clearly “articulated their concerns”.36 Their concerns could not have been clearer. They were concerned that Letby was deliberately harming children and that the trigger for speaking out was Baby O’s death the previous day. I accept that neither of them said directly, ‘Letby is killing babies’ or ‘Letby is murdering babies’, but their concerns as expressed could mean only one thing. I accept that it is hard to say out loud that someone is murdering tiny babies. Anyone in the hearing room will remember the silence there was each time counsel used the words ‘murder’ or ‘killing’. And that was in the context of an Inquiry that came into being because a nurse had been convicted of killing babies. It is still truly shocking to hear.
- The other part of Ms Kelly’s explanation was that the doctors did not ‘articulate the facts’ and explain how they had come to have those concerns.37 It was not for Ms Kelly to assess the detail underpinning the concerns. She knew that babies were dying, she knew that their deaths were unexpected and that many were unexplained, she knew that one nurse had been present at most of the collapses and deaths. She knew that the doctors were very worried. As the head of safeguarding (see Chapter 12), she knew she had to act when there was a suspicion that a baby had been harmed and that others may be at risk. She did not do so.
- Ms Kelly was asked what she did after receiving the information. She responded: “Personally I didn’t do anything after I spoke to Karen because as I mentioned before my duties are discharged to my team, I — I have Karen Rees held in very high regard. She was going to do a set of actions and I was happy with that.”38 Given the nature of the concerns conveyed by the consultants, I cannot see how Ms Kelly was comfortable to delegate (or, as she put it, ‘discharge’) her responsibilities to Ms Rees, her junior by two management levels. Ms Kelly had been at the meeting in May 2016 at which Dr Brearey had expressed his concerns. She knew that there was monitoring of the deaths after that meeting, and that day, Baby O had died. This was not delegating; it was abdicating responsibility.
- The “set of actions” to which Ms Kelly referred in evidence amounted to Ms Rees going to the neonatal unit to speak to Ms Powell, who, as I have said above, was not in the hospital that day. She spoke instead to Ms Farmer and asked whether she had any concerns about the competence of any of the nurses on the neonatal unit. She did not ask her about Letby; she did not mention the doctors’ suspicions. Ms Farmer “gave me assurance saying: absolutely not”.39 Competence was not the issue. No one on the neonatal unit thought that any of the nurses were incompetent. The concern was about deliberate harm. This action could not and did not deal with the concerns at all.
- Ms Rees was asked why she did not ask Ms Farmer outright whether she had concerns that a nurse was deliberately harming babies. She responded that if the senior nurses had these concerns, “I think that would have been brought to my attention rather than wait for me to ask it”.40 She may have been right about that, but her approach meant that her mind was closed to the possibility that harm was being done. Going to see Ms Powell (in the end, Ms Farmer) was an empty exercise. Because the senior nurses had not brought anything to her attention, she was satisfied there was nothing to be brought to her attention, and did not even ask about deliberate harm. This underlines the foolishness of Ms Kelly taking reassurance from Ms Rees’s “set of actions”. There was one action which would undoubtedly give assurance, which was neither sought nor obtained – removing Letby from the neonatal unit.
The evening of 24 June 2016
- Dr Brearey spoke to Ms Rees by telephone in the early evening on Friday 24 June 2016. She was at home when she received the call.41
- Dr Brearey gave oral evidence that, on the evening of 24 June 2016, he called the hospital switchboard and asked to speak to the duty executive. He emphasised that he did not ask to speak to Ms Rees specifically; however, she was on duty and answered. Dr Brearey said that he informed her that Baby P had died, and that he was concerned that Letby may be working the next day.42 Dr Brearey explained:
“I wanted the neonatal unit to be safe and the only way for us to be sure that it was safe at that stage was for her not to come to work the following day.
Karen Rees then as I have described previously said no to this. She said that I had no evidence, was quite categorical. I said: well, if you are saying ‘no’, does that mean that you — that you are happy to take responsibility if anything were to happen on the following day with any further babies and override the wishes of seven Consultants? And she said ‘yes’ to both of these.”43
- Ms Rees disagreed with some of Dr Brearey’s evidence about the phone call. She believed he had telephoned her directly, somehow obtaining her number.44 I think that is unlikely. Dr Brearey was extremely concerned. He wanted to speak to a senior executive. He got Ms Rees.
- Ms Rees agreed that Dr Brearey asked her to remove Letby from the unit, and she reiterated that she would not do this without further information or “just cause”.45 She denied telling Dr Brearey she would take responsibility for Letby remaining on the neonatal unit.46 That is puzzling. In refusing to remove Letby from the unit, which she undoubtedly did, she was taking responsibility for her remaining there. I cannot see why she would not say so to Dr Brearey when he asked her, as I find he did, and she refused to remove Letby from the neonatal unit. Her view that she could not remove Letby from the unit without further information or ‘just cause’ ignored the doctors’ concerns. She knew that at least two paediatricians were concerned that Letby was deliberately harming babies. She had known for some months that babies were dying on the unit and that at least some of the deaths could not be explained. She knew that Letby was on shift for many of them. The safety of the babies on the unit should have been her paramount concern. Instead, she used the language of ‘just cause’, putting first the interests of the nurse. That she was hostile to Dr Brearey was revealed in this exchange:
“Mr Baker KC: All Stephen Brearey is asking you to do is to take Lucy Letby off the ward so she doesn’t harm another baby, that is all he was asking, wasn’t it?
Ms Rees: Yes, he was demanding. He wasn’t asking, he was demanding, yes.
Mr Baker KC: Did that put your back up, that he was demanding it?
Ms Rees: I wouldn’t say put my back up but why wasn’t he working with me? You know, like I have said previously just because a Consultant makes a demand, as [a] senior nurse, you — you don’t — when they click their fingers you don’t jump how high.”47
She added: “I mean, I accept, and looking back at all of these things, yes, and that is why we are here today so we can learn lessons and I am sorry for all of that.”48
- The truth is that Ms Rees did not accept that the doctors’ concerns were held in good faith. As she said in evidence, she believed that there was a personal motive behind Dr Brearey’s request.49 Her first thought, when being asked by Dr Brearey to stop Letby coming on the unit the next day, was that Dr Brearey and Letby were, or had been, in a relationship. This, she surmised, caused Dr Brearey to seek Letby’s removal from the neonatal unit. This was ridiculous. It is not clear to me that Ms Rees ever properly thought it through. There was no evidence in support of this theory, but she believed it. That is why she later asked Letby whether Dr Brearey had ever made a pass at her. Letby made it clear that he had not.50 When asked to explain in evidence why she had formed that view, she related her experience of having consultants on another ward, where she was the ward manager, demand that she remove nurses either from their team or from their ward or unit, because personal and professional relationships had broken down.51 She refused, quite rightly. That was the basis for her belief that there was a relationship between Dr Brearey and Letby, and that he was seeking her removal in bad faith. In other words, there was no basis for it at all.
- Everything about Ms Rees’s reaction here was wrong. First, she was dealing with paediatricians of whom she had little knowledge or experience. Second, there was nothing to support her theory. A moment’s thought would have led her to acknowledge that falsely accusing a nursing colleague of harming (or even killing) babies would be an extreme way of removing a nurse from a unit. What is worse, when she rang Ms Kelly on 24 June 2016, she told her that her view was that there was something personal between Dr Brearey and Letby. Ms Kelly confirmed this in evidence.52 That unfounded allegation, having been made, went round the hospital like wildfire and came to feature in the grievance many months later.
- That Ms Rees was comfortable making such an extreme allegation against a paediatrician without any basis demonstrates that she had lost all judgement in the face of what she had been told. Whether this was because of her long-standing belief that nurses were not treated with the same respect as doctors, or her conviction that there was nothing in the doctors’ concerns, her hostile approach was deeply unfortunate, and it would continue for many months. She was later to assert in the grievance and in evidence that she felt that Dr Brearey bullied her in the conversation on 24 June 2016.53 She did not suggest that he was openly aggressive. Instead, she described him as passive aggressive.54 It is plain on the evidence that he was desperate to get Letby off the ward, and she was determined not to agree to it. She objected to being told that she would be responsible for the consequences of her decision. This was not bullying, nor did she experience it as such. I say that having considered all the evidence about her and about Dr Brearey. Against that backdrop, I also observed Dr Brearey in the witness box for a prolonged period, and Ms Rees in the witness box for long enough to assess the likelihood of her being bullied by anyone, still less Dr Brearey. The likelihood is nil.
- In evidence, Ms Rees said: “I’ve been in to see Alison Kelly and she is discussing the whole episode of that afternoon with Ian Harvey.”55 Mr Harvey has no memory of anyone speaking to him about this on 24 June 2016. Ultimately, no steps were taken to prevent Letby from working on the neonatal unit. This was a failure of all the managers involved. Ms Rees, Ms Townsend and Ms Kelly.
- Ms Townsend was asked why she did not take action to remove Letby from the unit. She stated she thought the concerns lacked detail and needed further investigation.56 Of Dr Brearey and Dr Jayaram, she said: “I do feel if there was that urgency … they could have gone direct to the Executives themselves.”57 This too was abdication of responsibility. The appropriate route for a doctor was to go through the management structure. Dr Jayaram had raised it with Ms Townsend who, extraordinarily, sent it down the chain rather than up. Dr Brearey had sought to speak to the duty executive on 24 June 2016. He was put through to Ms Rees. The doctors were not to blame for Ms Townsend’s failure to escalate this issue to Ms Kelly and Mr Harvey as she should have done. She was Divisional Director. She could take decisions about the deployment of nurses. The fact that the doctors did not go over her head was not a justification for her own failure to take action to safeguard babies on the unit.
- Ms Townsend was asked whether she thought it was safe to go home that Friday afternoon without taking any action. She responded that she believed Ms Rees had spoken to Dr Jayaram and Dr Brearey, and later with two of the executives, and left it with the executives. She stated that, from their perspective, “little else” could have been achieved that day because the consultants were not forthcoming with further details.58 No details were needed beyond the fact that there were a number of babies who had died, without explanation, and the doctors were concerned that a nurse may be behind it. It is not apparent that she gave any thought to any potential harm to babies, or to the need for safeguarding steps. As a matter of fact, several of the deaths had occurred at night. Deaths at night stopped when Letby was moved to day shifts. Baby O and Baby P had died during the day. On any view, this was sufficient to require action to safeguard the other babies on the unit. Removing Letby to protect babies was an obvious step, neutral in HR terms, but not even considered. Ms Townsend did not seek HR advice, or consult any person senior to herself.
- Ms Rees conceded that she did not take steps to speak to the other consultants about their views on the cause of the neonatal deaths and collapses.59 She accepted that she “possibly” had a degree of bias in her decision-making when she concluded that the consultants had a personal issue with Letby.60 She came to that view almost immediately. She was biased against the doctors.
- Ms Rees was asked whether she thought she should have contacted Safeguarding when she became aware that the consultants suspected that Letby may be deliberately harming babies. She responded:
“I have reflected upon that and perhaps that is what – that’s an action I should have perhaps taken on Friday. But equally neither Consultant did neither. I just think yes, on reflection, I perhaps should have done and I am sorry for that. I am sorry.”61
That she should have taken steps to protect babies is inescapable.
- In oral evidence, Ms Kelly was asked why she took no action. Ms Kelly replied that she understood that Ms Rees had been to the unit, and the nursing staff did not have any concerns about any staff on the unit, including Letby, working over the weekend.62 She stated: “I had that assurance from Karen [Rees] that staffing had been reviewed and everyone was satisfied.”63 I have dealt with that earlier in this chapter.
- Ms Kelly conceded: “What I didn’t ask or didn’t clarify was whether she was on duty the day after and I should have done.”64 She also conceded that she did not approach Dr Brearey or Dr Jayaram about their concerns.65 She should have done both.
- Ms Kelly told the Inquiry: “[O]n reflection, I — I — I could have done something differently and maybe that was a missed opportunity.”66 She sought to explain why she did nothing: “[I]t was a very difficult thing to hear. So maybe I didn’t, I didn’t process it as — as I should have done at the time.”67 In my judgement, she should have done a lot of things differently. The language of missed opportunity is wholly inapposite when talking about the failure to protect small babies. This was not something that ‘could have been done differently’. It was a gross error. She should have done something differently; that is, removed Letby from the neonatal unit.
Infection
- An email from Ms Townsend to Dr Brearey on 28 June 2016 set out several action points that were made in response to the consultant paediatricians raising concerns about the deaths. One of these included: “Microbiology/infection control review to be undertaken within the NNU … to undertake Deep Clean of the unit.”68 The ‘Position Paper: Neonatal Unit Mortality’ confirmed that an infection control review occurred.69 There was no evidence that infection caused any death.
Pseudomonas
- Several witnesses (consultant paediatricians and nurses) raised the question of pseudomonas. Ms Powell told the Inquiry: “We had two incidences of pseudomonas. And that was tested. The estates came to test … filters then had to be applied to the taps and then they were retested.”70 In line with Ms Powell’s evidence, a document titled ‘Time Lines of External Influences on the Neonatal Unit March 2012–July 2016’ sets out that pseudomonas was found in the taps twice, once on 31 December 2012 and again on 14 December 2015.71
- A contemporaneous note from a meeting that took place between the executives and the consultant paediatricians on 29 June 2016 records Dr Brearey saying: “Pseudomonas growing from taps but not evident in incidents.”72 There was no evidence that pseudomonas played any part in any of the deaths on the neonatal unit.
RSV
- On 12 April 2016, Ms Millward wrote to CQC to confirm that there had been no outbreak of a respiratory virus on the ward. She stated: “RSV outbreak: An issue was identified with the testing of the samples sent to the laboratory … In summary – the Trust did not have an outbreak of RSV on the NeoNatal Unit and it would appear that the issue was with the testing kits.”73 A Countess document, ‘Time Lines of External Influences on the Neonatal Unit March 2012–July 2016’, makes it clear: “RSV OUTBREAK (FALSE POSITIVE) – FEB 2016.”74
Mortality review of Baby O’s and Baby P’s deaths
- Dr U attended a review of the deaths of Baby O and Baby P on 5 July 2016. The meeting was also attended by Dr Brearey, Dr ZA, Ms Powell, Ms Griffiths, Ms Sian Williams and Ms Cooper. Dr U was asked about Dr ZA’s oral evidence that concerns about Letby were discussed at this meeting; Dr U could not recall these concerns being discussed. It is highly unlikely that they were not. He said that at some point he left the meeting and the conversation continued. He emphasised that he was not aware of his colleagues’ concerns about Letby at this time and that he did not have concerns.75
- Dr U was taken to a message which he sent to Letby following the meeting (Dr U to Letby on 6 July 2016 at 00:54):
“You need to keep this to yourself [emphasis added]. The meeting this afternoon looked at everything with Child O and P from birth onwards, reviewed everything, the room, beds, medical views and actions. We looked at all documentation, medicine. If you have any doubt about how good you are at your job stop now, documentation was perfect. Everyone commented about the appropriateness of your request for review following the vomits.”76
- Dr U was asked why he sent that message to Letby when she had not been invited to the meeting. He replied that he was seeking to reassure her because she was upset by the deaths.77 He went further than that. Dr Brearey emailed him on 6 July 2016. He said that there was likely to be an inquest into the deaths of Baby O and Baby P. He suggested that Dr U prepare a statement while matters were fresh in his mind, and said that the statement “can include things we discussed yesterday that might not be in the notes”.78 Dr U could not remember what was not in the notes of the meeting of 5 July, but accepted it may have been about Letby. He had not been present towards the end of the meeting.79
- Dr U most unwisely forwarded Dr Brearey’s email to Letby. He wrote: “[T]his email has to stay between us, is that okay.”* He was asked why he sent the email to Letby. Again, Dr U stated that he was trying to reassure her and “give her some insight into what was going on”. He then added: “[I]n hindsight that was an error on my part” and “I shouldn’t have sent it”.80 I agree with him. It is another example of the blurring of boundaries. Here, between his duties to his patients, and his desire to help and support a young nurse who had, as he did not realise, many people supporting her. He put her first.
- His support for Letby continued well into 2017.
25 June 2016, Baby Q
- Letby remained on the shift rota and worked on Saturday 25 June 2016. Given the concerns at this stage, this should not have happened.
- Baby Q was born at 31 weeks and 3 days’ gestation, and weighed 2.076 kilograms. On 25 June 2016, Baby Q collapsed unexpectedly.81 Letby was Baby Q’s designated nurse on the day shift.
- In Baby Q’s nursing notes, Letby records: “09:10 attended to by S/N [senior nurse] Lappalainen – He had vomited clear fluid nasally and from mouth, desaturation and bradycardia, mottled ++. Neopuff and suction applied. Doctor U attended. Air++ aspirated from NG [nasogastric] tube.”82 Letby was charged with Baby Q’s attempted murder. The prosecution’s case was that around 9am on 25 June 2016, Letby injected air and clear fluid into Baby Q’s stomach via his nasogastric tube. The jury were unable to reach a verdict.
- Ms Kelly has told the Inquiry that she was not informed about Baby Q’s collapse. She said she would have expected to be notified, given what was agreed at the 11 May 2016 meeting in relation to being informed of all unexpected collapses. I agree she should have been notified, but in light of the response to the deaths of Baby O and Baby P, I doubt it would have made any difference.
- Dr Brearey accepted Baby Q’s collapse should have been reviewed at the time, and there should have been a discussion with Parents Q.83 He explained this did not take place because of the number of meetings that happened following the deaths of Baby O and Baby P.84 He also pointed out that, following Baby Q’s collapse, Mr Harvey and Ms Kelly promised a review into the deaths, and that was how the matter would be taken forward (see Chapter 14). In Dr Brearey’s view, from this point Mr Harvey took over communication with the families and the additional investigations being carried out.
- After Baby Q’s collapse, on 25 June 2016, Dr Gibbs told the Inquiry that he asked the nurses which nurse was looking after Baby Q. He said that he was expecting that his question would get back to all the nursing staff. He explained that it was his “rather feeble attempt to try and offer some protection, if some harm was going on”, by monitoring who was caring for which babies.85
- Dr Gibbs’ question did get back to Letby. That evening, on 25 June 2016, she exchanged messages with Dr U. I have set some of them out below:
22:46, Letby to Dr U: “Do I need to be worried about what Dr Gibbs was asking?”
22:54, Dr U to Letby: “No.”
22:58, Dr U to Letby: “He was asking to make sure that normal procedures were being carried out.”
…
23:25, Dr U to Letby: “Lucy, if anyone knows how hard you’ve worked over the last three days it’s me … if anybody [emphasis in original] says anything to you about not being good enough or performing adequately I want you to promise me that you’ll give my details to provide a statement.”86
- Dr U was asked what he understood Letby was worried about. He responded: “I think, having looked after the two babies on consecutive days, she was concerned that she would be thought to be responsible for the deaths.”87 Dr U stated that he was trying to reassure her because he was aware that she had mental health problems. He told the Inquiry that he mistook her behaviour at the time for anxiety. However, he agreed that “in hindsight, yes”, she was worried about people asking questions about the deaths.88
- Like other parents, Mother Q did not know that Baby Q had suffered a collapse at the Countess. She was informed by the police.89 Her evidence to the police was: “I think that they played everything down to protect the parents and prevent panic, but I feel that this was not fair to us as we needed to know what was happening to our child.”90 I agree. It was not for the medical and nursing staff to decide what was best for the parents. Their duty was to be candid. I accept that such situations are difficult and demanding. I also accept that doctors and nurses are often working under great pressure of time. Each case will be different in terms of the timing and content of any communication with parents. But communication there must be. The duty of candour requires it.
- Mother Q’s victim impact statement from the criminal trial was disclosed to the Inquiry. Mother Q wrote: “One thing that I really struggle with is, this had been going on for such a long time and Child Q was the last one if she would have been caught before, this wouldn’t of happened to Child Q.”91
- Before turning to what happened next, I consider a matter of central importance. Safeguarding.
Footnotes
* This message was sent on 7 July 2016 at 00:05.