Chapter 13. Why was action not taken sooner?

Among the questions to be answered by this Inquiry are: should suspicions have been raised earlier? And, what were the responses to concerns raised about Letby from those with management responsibilities within the Trust?
In this chapter I consider the actions and decisions of doctors and managers from mid-June 2015 to mid-June 2016.

Unthinkable

I start by acknowledging that the idea that anyone would deliberately harm and even kill tiny babies is repugnant. That a nurse would do so is often said to be unthinkable.
Because it is too hard to accept, declaring something unthinkable avoids having to confront it. We know that sometimes, albeit very rarely, nurses and doctors deliberately harm and kill patients, including very young children and very elderly people. The case of Harold Shipman, a well-regarded GP who murdered approximately 250 elderly patients, is probably the most well known. The case of Beverly Allitt, a nurse at Grantham and Kesteven General Hospital who killed patients (including children) by poisoning them with insulin, is another. Some years after her trial she admitted the offences. There are others: in May 2015, very shortly before the first deaths at the Countess, Victorino Chua, a nurse at Stepping Hill Hospital, was convicted of two offences of murder, also by insulin poisoning. Before he was arrested, another nurse had been arrested and held on remand in custody for six weeks. She was released and no further proceedings were taken against her. Stepping Hill Hospital is about 35 miles from the Countess. The case was clearly known about at the Countess. It was mentioned by a number of witnesses (Mr Harvey¹ and Dr Gibbs² in particular) as an example of a mistake made in circumstances where a nurse was on duty at the time of deaths and, for a while, was wrongly accused. This undoubtedly featured in the thinking of doctors and managers. Mr Harvey seems to have regarded the case of Stepping Hill Hospital as a counter-balance to the Allitt case. Being alert to the possibility of a mistaken link being made between deaths and the presence on shift of a nurse was reasonable, but the injustice done to the first nurse did not negate the fact that a nurse, Victorino Chua, had murdered patients, just as Allitt had done. Nurses do kill. It is not unthinkable. All doctors, nurses and managers should know that.
For most of 2015, the fact that someone was or might be harming babies did not cross anyone’s mind. It is likely that all considered such a situation as unthinkable, not because they did not know about the cases I have referred to (at least the case of Victorino Chua) but because those cases occurred somewhere else. They did not involve a person or people known to the nurses and doctors at the Countess. As Ms Kelly put it: “I suppose we found it quite — we found it quite difficult to kind of comprehend, really … The last thing on my mind is that one of my nurses is — is deliberately harming children or babies or adults.”³
She was not alone in thinking like that. Many witnesses, both doctors and nurses, described it as unthinkable. Professor Mary Dixon-Woods, Professor of Healthcare Improvement Studies at the University of Cambridge, made the point in her report that it is harder to raise concerns about someone who is known.⁴ That was the case at the Countess. Letby was known, liked by many, and her manager considered her an excellent nurse.
Raising concerns is easier when there is objective evidence of deliberate harm. The insulin results in respect of Baby F and Baby L were clear, objective evidence of wrongdoing, the first in August 2015. As I have set out in Chapter 5 in respect of Baby F, the consultant considered it not just unthinkable but fantastical and so took no action, Baby F having apparently recovered. In respect of Baby L, later, the significance of the test results was overlooked by Dr U (see Chapter 8). Had either of these results been raised with managers it is likely that, whatever the reputational risk, contacting the police would have been unavoidable. Mr Harvey was very firm in evidence about the difference that information would have made to him.⁵
The fact of numerous deaths was, in itself, a matter of concern. But to move from a concern about that to a concern about deliberate harm requires a significant shift. The absence of hard evidence makes it even more difficult to consider still less to conclude there may be someone deliberately harming babies. Professor Dixon-Woods spoke about this in her report and in evidence. Her expert evidence reflects precisely what happened at the Countess.⁶

Emerging concerns

The fact that Letby was usually on shift when babies collapsed and died unexpectedly was obvious to Dr Brearey and Ms Powell but it is to be remembered that no one ever said they had seen Letby doing anything untoward to a baby. Ms Powell considered her an excellent nurse who did a lot of shifts and so was more likely to be present at deaths. She also mentioned repeatedly that Letby was well qualified.⁷ In fact, she was one of the more junior nurses on the neonatal unit at band 5. Evidence of her failings and worrying behaviour was not shared and so these were not part of the picture being pieced together by Dr Brearey.
Dr Brearey was concerned about the number of deaths on the neonatal unit from June 2015. In a unit where the annual rate of deaths was between one and three, the occurrence of three deaths in a fortnight was unheard of and did cause concern. Dr Brearey has spent most of the last ten years or so reliving many of the events about which he gave evidence. It is not easy to unknow the fact that Letby was convicted of murdering seven babies and of attempting to murder another seven babies (eight offences). Knowing those shocking facts is likely to colour his (and others’) views of what he did or did not know and think in 2015.
Maintaining focus on what was said and done at the time, there is no evidence that during June, July or August 2015 he had any thought that anyone might have deliberately harmed a baby. In his evidence in November 2024, he spoke of having a nagging concern; that arose from the fact that Letby was on shift when each of the babies died.⁸ These were, using Professor Dixon-Woods’ words, emerging concerns, which are harder to voice.⁹ I have set out elsewhere Dr Brearey’s detailed approach to the deaths, his investigations and conclusions. I bear in mind that in 2015 there were, on the face of it, medically plausible explanations at post-mortem for Baby C and Baby D, and the post-mortem for Baby A was still awaited. There was no obvious medical or other common denominator (such as infection) to link the deaths. Because it was thought, wrongly, that Baby E’s death had been caused by necrotising enterocolitis (NEC), there was no post-mortem.
It would have been better had the collapse of Baby B been considered alongside the deaths of Baby A, Baby C and Baby D, and had more attention been paid by Dr Brearey to the concerns about rashes/skin mottling, but those observations are made with the benefit of hindsight. Some doctors would have looked at Baby A and Baby B together, given that they were twins, but some (reasonably) would not have. The same applies to the rashes/skin mottling. Mr Harvey was also to observe later, correctly, that there were post-mortems that explained the deaths as natural. Neither he nor Dr Brearey had at that time any reason to believe that the findings of the post-mortems may not correctly explain the deaths. The difference between them was that, as the position changed, Mr Harvey remained fixed in his thinking, whereas Dr Brearey kept questioning himself and the findings, looking for explanations and, in due course, challenging the effect of the post-mortem findings, particularly where the cause of death appeared natural but did not explain the collapse.
The death of Baby I in October 2015 caused a shift in the attitude of some of the consultant paediatricians. Corridor conversations about Letby began between Dr Brearey, Dr Jayaram and other consultants in light of their concerns about the circumstances of Baby I’s collapses and death. At that time, Dr Gibbs said that he did not think Letby was deliberately harming babies; he disagreed with Dr Brearey, but that changed over time.¹⁰ Dr Gibbs exemplified the struggles the paediatricians had in acknowledging, even to themselves, that a nurse might deliberately be harming babies. He had been concerned about the cause of Baby C’s death but eventually accepted the pathologist’s view, notwithstanding his own views, which he had shared with Mother C.¹¹ Later than Dr Brearey and Dr Jayaram, he too was satisfied that Letby was responsible for the deaths. This interaction between the doctors, all of whom were trying to do the right thing, underlines how hard it is for each individual to be confident that their suspicion is even worthy of action. They all shied away from the shocking reality. Dr Jayaram internalised his concerns about seeing Letby doing nothing to help Baby K in February 2016. Dr Gibbs said that he believed it was after he read the Thematic Review and realised how many deaths there were that he began to have suspicions about Letby.

Thematic Review

The Thematic Review, completed in March 2016, should have led to questions from those who read it.¹² Some of them asked why the review did not make explicit in the main text that the same nurse had been on duty on every occasion an unexpected collapse and death had occurred. Instead, that information could only be found by reading the appendix. The evidence shows that people did not read the appendix. Another question is: why did the review not say that any sudden and unexplained collapse of a neonate is of itself a cause for concern, and there were several? As Dr Hawdon, a consultant neonatologist and Medical Director at the Royal Free Hospital, said in evidence (see Chapter 21): “[F]or a clinician to be told that a number of deaths are unexpected and unexplained is a message in itself.”¹³ Dr Alan Fletcher, the former National Medical Examiner for England and Wales, agreed with that in evidence: “[T]he Sudden and Unexpected Death of a baby in a neonatal unit is an outstanding and remarkable matter. So in [and] of itself I would expect that occurrence to generate … a heightened sense of concern about what happened, what led up to it, what the response was, and why it happened.”¹⁴ The phrase ‘heightened sense of concern’ describes well the response to the sudden and unexpected death of a baby in a neonatal unit. Mr Harvey seemed surprised by this when Dr Hawdon emailed him to that effect in answer to his direct question in April 2017.¹⁵ Had Mr Harvey asked the paediatricians the same question at any point, they would have given the same answer as Dr Hawdon.
In my view, even in March 2016 the review writers were not confident that Letby was harming babies, but they saw the association and had concerns about the number of deaths, the timing of the deaths and the sudden and unexpected nature of the collapses. No one was confident enough to say directly that they thought she was or even might be responsible (deliberately or otherwise). That was not due to anything the managers had said at that point – for nothing much had been said – but because of the enormous consequences for everyone if they were wrong. This was, as Professor Dixon-Woods described, a barrier to raising concerns.¹⁶ As I have said elsewhere, the consequences would be graver if they were right, but self-doubt and hesitation prevailed. The writers set out, accurately, what was known. The review was provided to senior managers, seeking assistance and a way forward (see Chapter 6).

Conclusions

Senior nurses

The evidence makes it clear that for the senior nurses, the idea that Letby might be harming babies deliberately was and remained unthinkable from 2015 onwards. I have dealt with Ms Kelly’s position in detail. Ms Powell was steadfast in her defence of Letby. The nursing voice was loud and prevailed in the meeting on 11 May 2016, in the RCPCH report and with the senior managers (see Chapter 19).
Whether the senior nurses believed Letby was harming babies was not the issue. The question was: were there suspicions, genuinely held, that she was or may be doing so? Ms Powell considered it was “all nonsense”.¹⁷

The consultants

I have no doubt that the consultants’ concerns were held in good faith and were based on their clinical judgement. It is clear that they did not know what Letby was doing to harm babies (the two cases of insulin poisoning having been missed). This undermined their confidence and contributed to Dr Brearey being shouted down by the forthright and determined views of the senior nurses at the meeting on 11 May 2016. Dr Gibbs¹⁸ and Dr Brearey both acknowledged that they were influenced by the nurses’ views.¹⁹ These were not the arrogant, all-knowing consultants who so often appear in reviews of hospitals. They, like all their consultant colleagues, were worried about the babies and fearful of the consequences, for all concerned, of their own views. Later, in late June 2016 – after the unexpected and unexplained deaths of Baby O and Baby P and the situation had become extreme – Dr Brearey did not back down, and was supported by his fellow consultants. His change of approach was not welcomed by the managers (see Chapter 11).

The managers

I am satisfied that from the outset the senior managers, first Ms Kelly and Mr Harvey and, in late June 2016, Mr Chambers, dismissed the idea that Letby was deliberately harming babies. They did not believe it. This is what Professor Dixon-Woods described as the “credibility gap”.²⁰ But, as is clear from the previous chapter, whether the senior managers believed Letby was harming babies or not was irrelevant to their duties and responsibilities to take safeguarding action. It is striking that on 29 June 2016, Ms Kelly and Mr Harvey both believed that the doctors’ concerns meant that the police should be called, but by the end of that day they had accepted Mr Chambers’ view that other steps should be taken first, even though they both knew more about the detail of the concerns than he did. As Mr Harvey said in evidence, he regrets that they did not go to the police in June 2016.²¹
Mr Harvey said in evidence that he believed the doctors’ concerns were genuine but not justified. Neither he nor Mr Chambers was in a position at any stage to decide the concerns were not justified. Mr Chambers’ remark during his first meeting with the consultants expressing their concerns to him – “that would be convenient” – was offensive and suggests that he considered the concerns were not being raised in good faith.²² He could not remember saying that, but it fits his later actions.
A criticism of the doctors from the managers was that they had not called the police – the point being, presumably, that if their concerns were genuine they would have done so. The managers never considered whether the reason the doctors had not done so was because this was so serious that it needed to be dealt with at the most senior level of the hospital, exactly as Mr Harvey himself thought. That the consultants may have doubted themselves did not occur to the managers either. The managers did not, however, doubt themselves. The difference between them and the paediatricians was stark.

In summary

The blood test results of Baby F in August 2015 should have been brought to the attention of the Medical Director. Had Dr ZA raised these results with Dr Brearey and Dr Jayaram, it is highly probable that they would have raised them immediately with Mr Harvey and Ms Kelly. The executives (if necessary after informing Mr Chambers) should have called the police.
Dr Jayaram should have informed the Safeguarding Lead (Ms Kelly) or the Medical Director (Mr Harvey) about Baby K. Given that they ignored his concerns when he raised them in 2017, I cannot say that this would have led to protective action. It should have been done.
The insulin results of Baby L in April 2016 should not have been overlooked. They should have been brought to the attention of the Medical Director and the police should have been called.
In light of the serious concerns arising out of the Thematic Review and expressed at the meeting of 11 May 2016, the decision to watch and monitor for three months was wrong. Had urgent action to protect babies been taken after the meeting of 11 May, as it should have been, necessary advice would have been taken and Letby would have been moved off the unit pending investigations, other safeguarding action and referral to the police. Instead, six weeks after the 11 May meeting, Baby O and Baby P died.

Endnotes

Chapter 12

Safeguarding

Volume II

Cookies on The Thirlwall Inquiry

Chapter 13. Why was action not taken sooner?

Contents

Unthinkable

Emerging concerns

Thematic Review

Conclusions

Senior nurses

The consultants

The managers

In summary

Endnotes