Chapter 2. The neonatal unit, 2015 to 2016

Until July 2016, the neonatal unit at the Countess was designated a local neonatal unit Level 2. It provided care for babies born at or after 27 weeks’ gestation and with a birth weight of 800 grams or above. As a Level 2 unit, it was also equipped to treat twins and triplets from 28 weeks’ gestation or above. Babies who were born earlier than 27 weeks or those needing the highest level of care would generally be cared for in a Level 3 unit. There were Level 3 units at Alder Hey Children’s Hospital and Liverpool Women’s Hospital. Level 1 units provide special care and continuous monitoring, usually for babies born after 32 weeks’ gestation.
The Countess was one of the larger Level 2 units in the Cheshire and Merseyside Neonatal Network and had intensive care cots. It was equipped to provide intensive care to any baby for up to 48 hours. Longer-term or more complex care would require a transfer to a Level 3 unit. Because of the unpredictability of birth, there were occasions when, due to a lack of cots elsewhere, a Level 2 unit would need to provide short-term intensive care to babies until a transfer to a Level 3 unit could be made.¹
The neonatal unit was a separate unit within the Paediatric Department. The department had a paediatric inpatient ward with 34 beds for children up to 16 years of age, an outpatient clinic for the same aged children, clinics for babies who had required care on the neonatal unit, and clinics to which GPs and the Accident and Emergency Department could refer babies and children on an ad hoc basis.
The neonatal unit had 16 cots: 3 short-term intensive care cots, 3 high dependency care cots and 10 cots to deliver special care. There were four nurseries. Nursery 1 usually dealt with babies requiring intensive care. Nursery 2 was for high dependency babies and Nurseries 3 and 4 were allocated to special care and transitional care, that is, for babies who were being prepared to go home. Occupancy of the neonatal unit varied according to need. There were four additional transitional care cots on the maternity ward, which were looked after by midwives.
At the time of these events, the neonatal unit was cramped and outdated, had repeated problems with the plumbing and lacked facilities for mothers to stay with their babies. It was very inconveniently located on a different floor from the post-natal ward. The findings of the 2025 NHS Maternity and Neonatal Infrastructure Review show that such conditions are still common across the NHS.² In the absence of funding for better facilities at the Countess, a fundraising appeal, BabyGrow, was launched to raise £4 million for a new unit. Letby was the public face of the campaign. By the end of June 2016, the fundraising had stalled at £2 million, and the appeal was closed in 2017. Funding was later made available for improvements: first, the neonatal unit was replaced in 2021; and then, in 2025, a large modern women and children’s unit opened, providing integrated family care for babies and their families (see Chapter 28).

Divisional structure

When the hospital was reorganised in 2009, the Women and Children’s Division was abolished along with the post of Clinical Director for Women and Children. Paediatrics (including neonatology) was placed in the Urgent Care Division with the very much larger Accident and Emergency Department. Maternity services, including obstetrics, were separated from paediatric services and neonatology, and were included in the Planned Care Division. Thus, at the time of these events, the Countess had three clinical divisions: Urgent Care, Planned Care, and Diagnostics and Pharmacy (see Figure 2). There was also a Corporate Services Division, which included estates, facilities, HR, IT and finance, as well as other corporate services.FiFigure

Figure 2: The Countess divisions, 2015 to 2017

Sources: Countess of Chester Hospital NHS Foundation Trust, Annual Report 2015/16 (https://www.coch.nhs.uk/media/133225/abdb_3091_coch-annual-report-2015-16-min-1-.pdf); Countess of Chester Hospital NHS Foundation Trust, Annual Report and Accounts 2016/17 (https://www.coch.nhs.uk/media/145316/rjr_chester_annual_report_and_accounts_2016-17_wit.pdf#page=135)

The Inquiry heard evidence which suggested there were broadly three issues with this structure. First, it led to problems in communication and cooperation between maternity services and paediatric services. Second, it resulted in mothers and their babies being admitted to and treated in separate divisions. Third, paediatric services, and in particular neonatology, found itself as a low-priority service within the Urgent Care Division.
In his oral evidence, Dr Ravi Jayaram, a consultant paediatrician and Lead Clinician for Children’s Services, described the issues as follows:
“We were allowed to keep a governance board but it was never clear to me where lines of escalation would go because obviously neonates sat in Urgent Care and maternity sat in Planned Care.
It also meant that as a specialty, paediatrics and neonatology had a much smaller voice.”³
Ms Yvonne Griffiths, Deputy Manager, neonatal unit (band 6 nurse), described how the structural separation affected relationships between midwives and nurses: “Unfortunately we were in different directives so we never really mixed in any meetings together … we didn’t have that cohesion that we do have now.”⁴
Some of these problems were identified and raised at the time. For instance, at a QSPEC meeting on 20 July 2015, the minutes of the meeting recorded Dr Brearey as saying:
“The Trust is well placed strategically to continue and improve its maternity/neonatal/paediatric services, however the current Divisional structure may hinder this. Colleagues continue to work across both Planned and Urgent Care Divisions with two sets of Managers and Matrons, who manage separate finance streams. There is usually no paediatric representation at the Urgent Care Divisional Board. Medical staffing concerns are agenda items but do not include paediatric medical staffing problems.”⁵
As Figure 2 shows, at a divisional level, paediatrics was grouped with HIV services and other unrelated services, such as rheumatology and palliative care. At an administrative level, as well as HIV services, paediatrics was also grouped with human milk bank and neurology.⁶ I am informed by the Countess that these services were all grouped together because there was a single business performance assistant who oversaw the management of the HIV service. I infer that this was not considered to be a full-time role and so the assistant also supported the other services, including paediatrics. It is not difficult to see how paediatrics could be overlooked.
Under the previous arrangements, the Clinical Director for Women and Children attended Board and management meetings, and regularly met the Medical Director and other clinical directors. When the post of Clinical Director for Women and Children was abolished in 2009, it was replaced by a Lead Clinician (for children’s services, at the time this was Dr Jayaram), who liaised with colleagues and managers in the Urgent Care Division but had no regular meetings with the Medical Director. Nor was he part of Board management and he did not attend any other Board meetings. I find it difficult to understand how that could have been thought a wise approach. This arrangement downgraded paediatrics and neonatology in terms of management and influence. They had no direct link to the Board. At least as important, probably, was the lack of personal contact, support and discussion between paediatrics/neonatology, senior managers and other Board members. There was almost no contact between senior managers and the neonatal unit – and reduced contact between the people working in maternity/obstetrics and paediatrics/neonatology.
The overall effect of the changed structure and administrative arrangements was to marginalise paediatrics and neonatology.

Women and Children’s Care Governance Board

The Women and Children’s Care Governance Board was introduced at the time of the reorganisation in 2009. I assume this was an attempt to maintain links between maternity services and paediatrics but it was not part of the governance structure of the hospital. This was a significant drawback.
The Chair of this board was Dr Jim McCormack, a consultant obstetrician and gynaecologist. The Deputy Chair was Ms Julie Fogarty, Head of Midwifery. As witnesses recognised, it would have been better had the Chair and Deputy been from different specialties. Obstetrics and maternity services were undoubtedly the bigger department, and this was reflected in their discussions, which tended to focus on obstetric and maternity issues.
Where the Women and Children’s Care Governance Board wished to do so, it could refer concerns to the Executive Team via the QSPEC. Ms Kelly received minutes of the meetings. The minutes of the meetings were also provided to the Urgent Care Divisional Board, on which Ms Karen Townsend, Divisional Director of the Urgent Care Division, sat. There was very little evidence before the Inquiry that either QSPEC or the Divisional Board was effective in bringing concerns to the Executive Team.
Ms Fogarty made the point that, before the reorganisation, obstetrics and paediatrics would jointly discuss issues.⁷ During 2015 and 2016, with the departments reporting through different divisional lines, silo working resulted, which hampered communication. This was entirely foreseeable. Ms Fogarty expressed the view that midwifery and obstetric staff would have been alerted to concerns on the neonatal unit sooner if they had been in one division, because there would have been more joint working and better communication.⁸ She is probably right about that.
Ms Anne Murphy, Lead Nurse for Children’s Services at the time, said she regarded paediatrics and neonatology as being in a “little bubble … [that was] segregated from the rest of the Trust”.⁹ One neonatal nurse observed, in her response to the questionnaire from the Inquiry: “[W]e felt like we were on our own. I think people were frightened to come and help because it was such a niche area of nursing.”¹⁰ This was echoed by other nurses on the unit. It is understandable that an adult or children’s nurse would feel diffident about looking after very small neonates, but the greater problem for the neonatal unit was its absence of profile at Divisional and Trust Board level.
Ms Yvonne Farmer, a neonatal practice development nurse (band 7) and a neonatal nurse (band 6), told the Inquiry that when neonatology was part of the Women and Children’s Division, she “personally knew” the management.¹¹ However, when it was placed into the Urgent Care Division, “there was a management tier that were quite unknown to me”.¹² She added that the management tier of the Urgent Care Division predominantly worked within adult medicine and “[s]o I felt they didn’t really know the needs of our unit”.¹³ There was also a practical change in that the senior managers responsible for neonatology were now in a separate building from the neonatal unit.¹⁴ Proximity is usually good for relationships within an organisation. Whilst these changes would not necessarily have affected the day-to-day running of the neonatal unit, physical distance and the ill-judged structure reduced the profile of an already small unit and led to it being isolated and overlooked.
Dr John Gibbs, the longest-serving consultant paediatrician and former paediatric Lead Clinician, said: “[W]e didn’t have a good relationship with the urgent care management, not because there was anything wrong with them but we were removed from them.”¹⁵ He also said that the consultants did not have a close relationship with the Executive Directors, whom the clinicians saw only occasionally.

Staffing levels: Nursing

The British Association of Perinatal Medicine (BAPM) had set out appropriate nursing staffing levels for use in NHS hospitals in 2010. Although the BAPM guidelines were issued to all units in 2010, there was no additional funding to help hospitals achieve these levels. The nursing staffing levels on the neonatal unit at the Countess were closer to target levels than the average across the network in the NHS North West region but did not achieve BAPM levels. Across the region, neonatal units were 27% below BAPM recommended nursing staffing levels. The figure for the Countess was 21% below the BAPM recommended levels.
The BAPM guidelines were used to support a business case to the Board for additional nursing staff for the neonatal unit in 2013/14 to no avail, and by 2015/16, changes to the staffing levels on the unit had still not been implemented.¹⁶ Ms Powell acknowledged that the risk described as ‘not compliant with staffing’ had been added to the divisional risk register in June 2010, that it was an ongoing feature, and that it had been an issue for as long as she had been the Manager of the neonatal unit.¹⁷ She encouraged nurses to file Datix forms about staffing whenever it arose. (Datix is a web-based system for incident reporting widely used by providers of NHS healthcare as part of local incident management arrangements.) Many of them did so. Ms Anne Murphy knew that there were concerns about the staffing levels within paediatrics, including on the neonatal unit.¹⁸
The pressure on staffing at the hospital generally (not specifically the neonatal unit) was identified by the Royal College of Nursing (RCN), which wrote to CQC pointing out staffing concerns in December 2015. CQC, which inspected the hospital in February 2016, noted the high level of bank staff (temporary staff available to take shifts when necessary) being used across the hospital generally.¹⁹ Again, this was a feature of staffing in many NHS hospitals.

Nursing team

A small team of nurses worked solely on the neonatal unit. A day shift on the neonatal unit usually had four or five nurses on duty: two experienced band 6 nurses, one or two band 5 nurses and a band 4 nursery nurse.²⁰ During night shifts, there would be fewer nurses on duty, usually four.²¹ The unit operated on the basis that a baby would always have a designated nurse. Nurses who were not allocated to a particular baby would support the designated nurses, taking their place during breaks and assisting whenever necessary.
As at the beginning of 2015, Ms Powell, a senior band 7 nurse, had been managing the unit since 2011. The other band 7 nurse on the unit was Ms Farmer. Ms Farmer had that banding for 50% of her time to devote to practice development for the nurses. This involved the induction of staff, educating nurses on the unit to further their practice and facilitating the undertaking of courses. For the rest of her time, she practised as a band 6 nurse. Ms Griffiths was the Deputy Manager.
All qualified nurses on the unit (bands 5, 6 and 7) were required to undertake the Foundations in Neonatal Care course and would progress after a few years to the Qualified in Specialty (QIS) course, a neonatal nursing qualification.²² In 2015 to 2016, there were approximately 18 band 6 nurses working on the unit; all had completed the QIS course, with some having additional qualifications (such as R23, Enhancing Neonatal Practice course). Band 6 nurses with an R23 qualification could act as shift leaders. Letby was one of two band 5 nurses who were QIS. There were also ten band 4 nursery assistant/nursery nurses.²³
The QIS was subject to a national review in 2021 by Health Education England in light of concern about a lack of consistency across the providers in training content, standards, length and other matters.²⁴ There is no suggestion that any of the nurses who had achieved QIS at the Countess had received substandard training. There was good evidence that nurses were competent and encouraged to develop their skills.

Doctors

I have retained the titles used by doctors at the relevant time. The neonatal unit was served by consultant paediatricians, middle grade junior doctors (registrars) and other junior doctors who were in their early years of postgraduate training for paediatrics or general practice. Paediatric trainees were on six-monthly rotation and GP trainees on four-monthly rotation. Dr Brearey was the Lead Clinician of the neonatal unit. As I have set out above, Dr Jayaram was the Lead Clinician for Children’s Services. All the doctors were based on the main paediatric ward and spent most of their time there.
There were seven consultant paediatricians supported by seven tier 1 doctors (i.e. qualified and in their third year of specialist training) and eight tier 2 doctors (i.e. qualified and in their first or second year of specialist training in paediatrics or general practice). The consultants operated a ‘consultant of the week’ rota, whereby each covered the children’s ward and the neonatal unit once every seven weeks, Monday to Sunday. There was a consultant ward round of the neonatal unit twice a week – on Wednesday and one day at the weekend. On the other days a registrar conducted the ward round and discussed findings and decisions with the consultant of the week later in the morning. There was an on-call consultant who covered nights for the children’s ward and neonatal unit from 16:30 to 08:30 Monday to Thursday. From July 2015, the consultant of the week undertook the role of on-call consultant for the children’s ward and neonatal unit on a Friday night and for 24 hours on a Sunday; Saturday was covered by another consultant.
All registrars and other junior doctors worked shifts: days, weekends and nights. At night, there was always a registrar on duty whose duties were spread across paediatrics (including the main paediatric ward), the neonatal unit and the Accident and Emergency Department. Whilst some nurses said that on occasion they had to wait for a doctor to attend when called, particularly at night, because the doctors were dealing with something else on the main paediatric ward or in the Accident and Emergency Department, the overwhelming preponderance of the evidence was that, whenever there was an urgent bleep, the doctor arrived swiftly.²⁵ It was plain from the evidence of the junior doctors that they were able to speak to consultants at any time, including at night when the consultant was on call. Consultants also attended the neonatal unit when asked, including at night.
There was a shortage of junior doctors and consultants, as in other NHS hospitals. In late 2015, Dr ZA, a consultant paediatrician, complained vociferously to Mr Chambers about the workload in the Paediatric Department. By that stage, the consultants had already made a business case to the Executive Directors for two additional consultants for the Paediatric Department, but they had been refused. Mr Chambers visited the neonatal unit (part of the Paediatric Department) in December 2015 and saw how busy it was. Subsequently, on 27 January 2016, the Executive Directors approved a business case for the two additional consultants.²⁶ Dr Susie Holt, a consultant paediatrician, joined the Countess in March 2016.²⁷ On 20 September 2016, Dr Jayaram followed up on the delay in appointing the second consultant, and was informed that this had been put on hold but would be reviewed again after the Royal College of Paediatrics and Child Health (RCPCH) had delivered its report.²⁸ This report is the subject of Chapter 20. Agreement to appoint an additional consultant was given in early 2017, and Dr Michael McGuigan, a consultant paediatrician, joined in January 2017.²⁹ He was the Clinical Lead for the Paediatric Department from December 2018 to December 2023.
The shortage of junior doctors could not always be covered by locums as the North West region had imposed a cap on their rates of pay. Most hospitals in the region had lifted the cap and so locum doctors tended not to choose the Countess.³⁰ In the absence of junior doctors, consultants covered those shifts in addition to their own duties.
I heard evidence from many junior doctors who had worked at the Countess for long or short spells at this time. Their views of the neonatal unit were almost all positive, emphasising the good and supportive working relationships across the unit, including between doctors and nurses. Only two doctors expressed reservations about the culture there and felt less supported. Whilst there was some suggestion from doctors that nursing staff felt consultant ward rounds were too infrequent, the overwhelming tenor of the evidence from doctors was a perception of good relationships with nursing staff, whom they viewed as dedicated and competent.
I accept the evidence from the junior doctors that – notwithstanding the pressures, none of which were unusual for NHS hospitals – the Countess was a popular choice for junior doctors because of its location and that it was friendly, supportive and caring. The consultants were, without exception, always available to and supportive of the junior doctors.

Workload

The nurses also often worked under pressure. Ms Farmer and Ms Griffiths described peaks and troughs. Others described the workload in similar terms. All the nurses acknowledged that everyone worked to keep the unit safe. People came in to do extra shifts, worked on rest days and were as flexible as possible to make sure that there was always adequate nursing staff cover on the unit.
Some nurses described the demands on the unit as particularly high during 2015 and 2016. Mr Christopher Booth, a senior neonatal practitioner (band 6) who had worked on the neonatal unit for over 20 years, described it as:
“an incredibly busy period with high acuity, and it was a demanding time for all team members … I do remember team members being asked to show greater flexibility with shifts worked and indeed, even being asked to work extra shifts on a regular basis. I do remember grumblings of us needing more registered nurses to help cope with the increased workload, but that did not seem to be forthcoming.”³¹
A band 4 neonatal nursery nurse, who had worked in Nursery 3 since 2008, recalled the period as being “very busy and stressful on the unit … We would sometimes miss breaks because it was that busy.”³² Ms Minna-Maria Lappalainen, a senior neonatal practitioner (band 6), expressed the same view in rather more stark terms: “Our staffing levels remained poor at times, especially during busy periods. This period was stressful and exhausting at times.”³³
A band 6 neonatal nurse noted: “At times, it felt staff were allocated infants above their capabilities due to the workloads occurring within the unit, relying on the nurse in charge or senior nurses to oversee their work.”³⁴ This concern was felt by another band 4 nursery nurse, who described being “asked to complete tasks that I was under qualified for i.e. babies that required a band 5/6 nurse. When I raised these concerns to fellow colleagues I felt very under supported.”³⁵
A band 6 neonatal nurse in her oral evidence to the Inquiry said that, in 2015 to 2016, “we were short-staffed”, and she went on to describe “a lot of pressure to deliver care during that time”.³⁶ She explained that nursing staff would often work through their breaks and stay behind after their shift to write up notes that they did not have the chance to record during the shift. However, she also referred to manageable shifts and, like others, to “peaks and troughs”.³⁷ Ms Farmer also mentioned some “quite stressful shifts”.³⁸
A band 6 senior neonatal practitioner described the unit as “busy” but noted that “most of the time it was manageable”.³⁹ This echoed the evidence of Ms Melanie Taylor, a neonatal nurse (band 6), who described the unit as “busy but manageable”.⁴⁰ Ms Taylor felt that the babies on the neonatal unit were all “within our realms of knowledge and care”.⁴¹

Relationships in the neonatal unit

Relationships between the nurses were generally very good and supportive. Many of them socialised outside work and they formed a cohesive team on the neonatal unit. I heard evidence and read statements from qualified nurses (bands 5 (entry level), 6 and 7) and from several nursery nurses and nursing assistants, who were designated at band 4 (and were not qualified or registered nurses). Some had been on the unit for many years, were very experienced and had good insight into the functioning of the unit.
Ms Powell, the unit Manager, was well regarded by most of the nurses working on the unit. There were some complaints that she had favourites amongst the nursing staff, including Letby, and there were some nurses she did not like. As a result, nurses perceived that her favourites were given more opportunities for training and development than others. As a matter of fact, Ms Powell held Letby in high regard. She considered her highly competent, willing to work hard and to volunteer for additional shifts. She liked her and she encouraged her. I note that Ms Powell’s Deputy Manager, Ms Griffiths, considered that Ms Powell was “very neutral” with the nurses on the unit and was a very good manager.⁴² A number of nurses commented positively that Ms Powell was very supportive of them. I accept that, generally speaking, Ms Powell was a very good manager and supportive of her nurses.
I am confident that the relationships between the nurses were generally very good, as they were between the junior doctors, between the consultants and between both groups of doctors. As part of the CQC inspection in February 2016, Ms Helen Cain (Acute Hospitals Inspector, CQC) interviewed Ms Powell. The notes of her interview record Ms Powell saying, “[b]rilliant relationship with consultants”.⁴³
By the time she wrote her statement for the Inquiry in 2024, Ms Powell’s tone and content were somewhat different. She wrote: “[T]he Consultants felt that all staff members worked cohesively but that was because the staff did exactly what they were told to do by the Consultants and did not challenge them.”⁴⁴ Counsel put that comment to Dr Gibbs, the most senior consultant in the Paediatric Department. Dr Gibbs said he was “disappointed and rather surprised” to hear that and did not agree. In his view, Ms Powell’s comment was a product of the “strong and unpleasant difference of opinion [held by consultants and senior nurses] about what was happening on the neonatal unit”.⁴⁵ I accept Dr Gibbs’ evidence about that, not least because almost every other nurse said the relationships with the doctors were very good until the suspicions about Letby were raised, when relationships gradually frayed. Given that Ms Powell described relationships as “brilliant” in 2016, it is clear that hindsight has distorted her recollection.
Most nurses considered that the generally positive culture of teamwork amongst the neonatal nurses extended to the relationships between nurses and doctors working on the unit. The view of Ms Griffiths, the Deputy Manager, was that there were no issues between the nurses and the doctors. Ms Ashleigh Hudson, a neonatal nurse (band 5), described the doctors as “approachable”, noting they had a presence on the unit or would respond to their bleep if called.⁴⁶
Ms Kathryn Percival-Calderbank, a senior neonatal practitioner (band 6), considered that the nurses got on well with the doctors, and commented that she felt able to tell the doctors if she disagreed with the management of a baby when such a situation arose.⁴⁷ This view was shared by Nurse W, a neonatal nurse (band 6), who described the relationships between doctors and nurses as “professional” and noted that the consultants were “respectful to the nurses” and that “they would listen to you as a nurse and respect your opinion”.⁴⁸ Ms Taylor also considered that doctors and nurses on the neonatal unit worked well together. She had no concerns about the communication between the two groups, viewed the consultants as approachable and “always felt listened to by the Consultants, even as a junior nurse”.⁴⁹
Ms Laura Eagles, a senior neonatal practitioner (band 6), recalled that nurses worked well with the doctors, particularly the registrars and senior house officers, and described the consultants as “approachable”.⁵⁰ Ms Abigail Lever, a neonatal nurse (band 5), likewise stated that there had “always been a really good working relationship between doctors and nurses”.⁵¹ Ms Joanne Williams, a neonatal nurse (band 6), commented on the close working relationship the nurses had with the registrars and senior house officers, whom she recalled were present on the neonatal unit most of the time when acuity was high.⁵²
Nurse Y, a neonatal nurse (band 6), described the registrars who were allocated to the neonatal unit as very experienced and as having a good rapport with the nurses.⁵³ As regards the nature of the relationship with the consultants, she said: “I have worked on the unit for a long time. From a personal point of view, I feel I have a good rapport with consultants.”⁵⁴ Ms Farmer shared these views, stating that nurses worked well with the medical team and that “on a personal level I didn’t have any problem with the Consultants”.⁵⁵
Two nurses were less positive about the relationship with the doctors. Nurse T, a neonatal nurse (band 6), said that if she expressed a differing view to a doctor about the management of a baby, “sometimes you felt you hadn’t been listened to”.⁵⁶ Another neonatal nurse expressed frustration that, in very busy periods, the medical team was slow overnight, “or if the team became busy on A&E [accident and emergency] or on the paediatrics unit”.⁵⁷ That, however, is about staffing rather than relationships, a view reinforced by Ms Ailsa Simpson, a senior neonatal practitioner (band 6):
“Sometimes when a baby required a senior review by a doctor, they wouldn’t always be available to attend straight away as they would be reviewing patients on the Children’s Ward first. Overall, despite the [busyness] of the NNU, the doctors and nurses on the NNU collaborated well together as a team and the atmosphere was happy at times, despite the stressful phases.”⁵⁸
Mr Booth, whilst considering that the unit “could have benefitted from the expertise of a neonatologist”, described the relationship between all the professionals during this period as good: “We were a strong, mutually supportive team and all worked well together for the wellbeing of our babies and their families.”⁵⁹
Having heard and read evidence from so many nurses and doctors who were working on the unit in 2015 and early 2016, I am confident that those working on the unit (doctors at all levels, nurses at all levels) respected and trusted each other and were engaged in a common endeavour to care for the babies on the unit to the best of their collective ability. Some had remarkable levels of empathy. I was particularly struck by the evidence of Ms Taylor, whose account of the way she looked after tiny babies in life and in death was very moving.

Relationships with midwives

The separation of neonatology and maternity services undermined relationships between nurses and midwives. Ms Eagles, having spoken positively about relationships between doctors and nurses on the neonatal unit, described the relationship between the neonatal unit and the obstetric teams as “more complex”:
“We, as nurses, would directly liaise with midwives. There was very little communication between us and the Obstetricians. If we had challenging conversations to have, we would ask our Consultants to speak with them. We would sometimes face discord from some senior midwives and ourselves. This would be in relation to when we were heading to full capacity or already at it and the midwifery team not valuing our concerns. It could be quite a struggle sometimes when we were full and them wanting to deliver a baby that would need our care and us not having room. We would ask them for help and some appreciation of our situation but would not get it. I cannot say this was all the time but it was quite common to have a struggle when we were getting full and or closed. If we, as a NNU team, felt the best thing for the pending admission was a transfer out, it would be very difficult to make this heard by the Obstetric team.”⁶⁰
Ms Caroline Oakley, a neonatal nurse (band 6), also discussed the strain in the relationship between the neonatal unit and obstetric teams, particularly when the midwives/obstetricians did not accept that the neonatal unit was at full capacity and could not admit any more babies. She said that neonatal nurses would report such incidents via the online reporting system, Datix.⁶¹
Nurse W gave evidence that “the senior midwives I didn’t feel were very approachable”; however, she said that some midwives were helpful and kind. She recalled receiving reports from parents that midwives would often not be available to take them to the neonatal unit to see their babies or participate in their babies’ ward rounds.⁶² This was also a concern expressed by some of the parents who gave evidence.
One of those parents was Mother H. She gave birth to Baby H via caesarean section and spent time as an inpatient on the maternity ward while Baby H was on the neonatal unit. Mother H required support travelling downstairs from the maternity ward to the neonatal unit until she recovered from the caesarean section. She said: “I wasn’t allowed to go on my own [to see Baby H] and I always had to let the midwives know if I was leaving.”⁶³
Mother H told the Inquiry there was an occasion where she had asked the midwives to take her to visit Baby H; however, she “was told there were no midwives available because again, it was a very, very busy time”.⁶⁴ Mother H said: “[I]t kind of felt like it was a bit of an inconvenience for me to ask somebody.”⁶⁵ She had to wait until Father H arrived at the hospital so he could accompany her to the neonatal unit.
By contrast, other parents had a positive experience with midwives facilitating visits to see their babies. Mother E and F told the Inquiry that, when Baby E was being resuscitated, the midwife took her down to the neonatal unit. She reflected: “I don’t think I would have been with Child E if it hadn’t have been for the midwife, because I heard her talking to the staff, saying, ‘It’s not fair, it’s not right. She’s his mum. She should be there with him. This isn’t right. She’s sat in a corridor’.”⁶⁶
In 2015/16, Ms Taylor “felt intimidated” and “overlooked” by the midwives and consultant obstetricians. However, she acknowledged that her perception of these colleagues has now improved.⁶⁷
Ms Kate Bissell, a neonatal nurse (band 6), described the relationship between nurses and midwives as “sometimes sort of difficult relationships”. In the context of dealing with babies and mothers, she explained that both professional groups “had their agenda” and “communication wasn’t always as good as it could be”.⁶⁸ Nurse T also described the relationship between neonatal nurses and midwives as being strained at times.⁶⁹ Ms Elizabeth Marshall, a neonatal assistant (band 4), also explained that, whilst the relationship between midwives and nurses had changed over time and was now improved, it was formerly “them and us”.⁷⁰
Ms Griffiths expressed the view that the relationship between midwives and nurses was not particularly strong because “we were in different directives so we never really mixed in any meetings together … we didn’t have that cohesion that we do have now”.^* ⁷¹
Ms Fogarty, the Head of Midwifery, did not accept that there were tensions between nurses and midwives. She said she did not experience any issues when she was a midwife working on the labour ward and no concerns were escalated to her subsequently as Head of Midwifery. Ms Fogarty also said she had no problems with Ms Powell, the neonatal unit Manager. Tellingly, however, she noted that they “didn’t see each other very much” and that communication would be “very, very infrequent”.⁷²
Ms Powell described neonatal unit staff going to the labour ward for the morning update on expected admissions to the unit and being ignored.⁷³ Ms Fogarty acknowledged that the organisational structure, which placed the maternity unit and the neonatal unit in different divisions, was problematic, describing maternity and neonatal services as working “independently”.⁷⁴ She also expressed the view that placing the neonatal unit in the Urgent Care Division, a large unit encompassing the Accident and Emergency Department, meant there were a lot of competing pressures within the division.⁷⁵ Her observation reflected the lowly position the neonatal unit occupied within the division and the separation of maternity and neonatal services.
Whatever the experience of the more senior midwives, it is plain on the balance of the evidence that, at this time, from the perspective of the neonatal unit, the relationship between them and the midwives was not easy. Apart from the senior midwives to whom I refer in the course of this Report, I did not hear from midwives about their relationships with the neonatal unit and I make no findings about the midwives’ conduct. Some tension between units and between neonatal nurses and midwives was perhaps to be expected when, from time to time, a baby was delivered and there was no cot available in the neonatal unit. However, lack of good relationships and poor communication, both at individual level between nurses and midwives and at management level, risks compromising patient care and patient safety.

Relationships between nurses and senior management

Nurses’ perceptions were that the executives visited the neonatal unit “very, very infrequently”.⁷⁶ They felt that senior managers were not listening to their concerns about the workload on the neonatal unit. Staff were completing Datix forms (as directed by Ms Powell), but “we just felt that nobody was really listening to us”.⁷⁷

Letby

Training

Letby began her pre-registration child nursing (BSc) programme at the University of Chester on 22 September 2008. The course consisted of university-based study and clinical placements with academic staff who were registered children’s nurses. Practical mentorship was provided by nurses, midwives or health visitors.
Throughout her training, feedback on Letby’s performance was mixed. Early assessments pointed out areas for improvement, particularly in relation to enthusiasm, communication with families and drug calculations. Academically, her personal tutor reported no concerns.
During her second and third years, Letby was mentored by Nurse T on the neonatal unit at the Countess. Nurse T consistently praised Letby’s knowledge, communication skills and engagement, stating she was among the best students she had mentored and noting no concerns about her skills or practice.
However, during her final placement in 2011, under the mentorship of Ms Nicola Lightfoot, Deputy Ward Manager of the Children’s Unit, significant concerns were raised. Ms Lightfoot observed that Letby was quiet, withdrawn and struggled to build relationships with children, families and colleagues.⁷⁸ Despite Letby’s efforts to address these issues, she failed a mid-year assessment and OSCE (Observed Structured Clinical Examination), and Ms Lightfoot ultimately concluded that Letby’s progress remained insufficient and did not sign off on her final assessment.
After discussions and an accelerated retrieval programme, Letby passed the OSCE and qualified as a registered children’s nurse in September 2011. She began working on the neonatal unit at the Countess in January 2012, initially on a temporary contract. A permanent band 5 post became available within days of her appointment. Ms Powell offered the permanent post to Letby, who accepted it.

Work and appraisals

Competencies and skills were assessed regularly at the hospital. These were usually signed off by Ms Farmer, who was responsible for training and development. The Inquiry has seen evidence that Letby passed all her assessments.
The Inquiry has seen copies of Letby’s appraisals covering the period from 2011 to 2017 – with the exception of 2014/15, of which no record has been found despite extensive searches by the hospital and the Inquiry. Overall performance was assessed by Ms Powell as ‘meeting expectations’ for 2011/12, by Ms Griffiths as ‘meeting expectations’ for 2012/13, and by Ms Farmer as ‘exceeding expectations’ for 2013/14. She had that year completed courses in resuscitation and in ITU, with a placement in the intensive therapy unit (ITU) of Liverpool Women’s Hospital.
The appraisal for 2015/16 was conducted in December 2016 by Ms Griffiths. She notes that Letby had undertaken a six-month secondment with the Risk and Patient Safety Department “in order to develop understanding and expertise within the Neonatal Unit”. This put a positive gloss on the move off the unit in July 2016, which is dealt with later in this Report. The appraisal also records that Letby had completed a placement at a Level 3 neonatal unit. This, I believe, is a reference to observations at Alder Hey. I deal with this in Chapter 17.
It is clear that Letby was considered to be a competent nurse by those assessing her. A morphine infusion error was not mentioned in her 2012/13 appraisal.

Morphine infusion error, July 2013

On 22 July 2013, at the end of a night shift, Letby and a senior nurse set a pump to infuse ten times the prescribed amount of morphine to a baby. Whilst no harm was in fact caused, the consequences could have been extremely serious. Ms Farmer confirmed it was Letby who incorrectly inputted the rate into the pump and the second nurse checked it.⁷⁹ The error was noted by Ms Shelley Tomlins, a neonatal nurse (band 5), at the start of the morning day shift. Ms Tomlins created a Datix report for the incident.⁸⁰
At the time of the incident, Ms Powell was on annual leave and Ms Griffiths was acting neonatal unit Manager. Ms Griffiths described the error as a “very serious incident” and one that could have been fatal.⁸¹ Ms Powell gave similar oral evidence. She told the Inquiry that the consequences, if not rectified, “could have been catastrophic” and caused a death.⁸²
Ms Griffiths commented on the difference between the responses of the two nurses. She said, “I just remember the comparison because I know the other lady was very distraught and very upset, to the point where she was going to leave nursing. Letby, I think she was upset but not to the same extent.”⁸³ Ms Griffiths pointed out that the other nurse came to find her on the day of the incident to discuss it; Letby did not.⁸⁴
The next day, on 23 July 2013, Letby and Ms Griffiths had a meeting about the incident. Before the meeting, Ms Griffiths sought advice from her matron on how to handle the situation.⁸⁵ One of the action points from the meeting was that Letby would “[refrain] from checking any intravenous infusions requiring additives and any controlled drugs until incident reviewed”.⁸⁶ Ms Griffiths gave evidence that she thought it was “safe practice to stop” Letby from doing the intravenous infusions until the incident was reviewed by a more senior member of staff.⁸⁷ This was obviously appropriate.
A further action point was for Letby to “complete intravenous competencies/drug calculation with practice development nurse (Yvonne Farmer)”.⁸⁸ Ms Griffiths explained that the normal process following a medication error was for staff to redo their competencies before they were permitted to do the relevant activity again.⁸⁹ In Ms Farmer’s view, the incident was a “very serious error”.⁹⁰ She thought Ms Griffiths had made a “good decision”.⁹¹
Ms Griffiths told the Inquiry that Letby “wasn’t happy” about the action points of the meeting.⁹² Given the severity of the error, Ms Griffiths did not deem it appropriate that Letby was unhappy.⁹³ Ms Farmer was asked about Letby’s reaction. She could not recall a previous situation where a nurse had responded like Letby.⁹⁴ She said that the other nurse almost resigned over the error and had a number of meetings with Ms Powell.⁹⁵ Perhaps surprisingly, Ms Farmer did not explore with Letby the reasons for the error.
Ms Farmer gave evidence that she did not undertake the practice calculations with Letby until 6 September 2013.⁹⁶ On 30 July 2013, Ms Powell had a meeting with Letby and determined she could “continue to care for infants [with …] infusions” and “is able to check CD’s [controlled drugs]”.⁹⁷ Ms Griffiths stated that Ms Powell had not spoken to her about these action points. She agreed that Ms Powell’s decision was a countermand to what she had decided.⁹⁸ This was an ill-judged decision given the seriousness of the error, the attitude of Letby and the clear action points set out by Ms Griffiths.
Letby’s text messages provide a degree of insight into her meeting with Ms Powell. At 14:07 on 30 July 2013, Letby messaged Nurse Z, a neonatal nurse (band 5):
“Eirian [Powell] was lovely. Feels it’s been blown out of proportion. Everything can go back to normal just need to do extra training on pump and have 3rd checker if setting up a CD [controlled drug] infusion for couple of weeks but otherwise carry on as I was.”⁹⁹
On 1 August 2013 at 09:18, Letby received a text message from ‘Ruth’, which read:
“Hi lucy how are you? What happened over the drug error?”
At 09:26, Letby responded:
“Thankfully Eirian felt it had been escalated more than it needed to be. Everything is back to how it was I just have to have more training on using the pumps and it will be on my record for [six] months. She was very supportive, a case of learning to live with it now and getting my confidence back.”¹⁰⁰
I accept that drug errors are made in hospitals, but it is not easy to see how a requirement that a nurse should be asked to practise the required competencies – having been involved in the administration of a potentially fatal dose of morphine – could be described as out of proportion to the error. Ms Griffiths did not think it had been escalated more than it needed to be.¹⁰¹ Letby was a very junior nurse and yet she achieved the downgrading of the response to her error.

How Letby was perceived by her nursing colleagues

The Inquiry legal team sent formal requests to 30 nurses who were involved in the clinical care or management of babies whose names appeared on the indictment around the time of an unexpected collapse and/or death. Questionnaires were sent to a further 20 nurses who worked on the neonatal unit and all 14 midwives who appeared in the hospital staff list.¹⁰² None of the nurses or midwives had any suspicions or concerns about Letby’s conduct in relation to harming babies while she worked on the neonatal unit.¹⁰³
Some nurses spoke positively about Letby and defended her. Ms Janet Cox, a nursery nurse (band 4) in 2015 to 2016, described Letby as “[a]n exemplary nurse who is completely innocent of all the alleged crimes”.¹⁰⁴ In her view, “certain Consultants, in particular Brearey, appeared to be trying to make Lucy a scapegoat for the increased number of deaths/collapses”.¹⁰⁵ Nurse Y sought to point out to the Inquiry that: “As a full time Band 5 neonatal practitioner who also worked regular overtime shifts with the relevant qualifications to care for intensive and high dependency care patients, Letby was regularly allocated the sicker infants on shift.”¹⁰⁶
Ms Ailsa Simpson, a band 6 nurse, did not have any concerns about Letby, but recalled:
“Letby involved herself with more babies than she needed to be involved in: For example, if a baby collapsed or required cardiopulmonary resuscitation but [Letby] wasn’t caring for that baby she would involve herself anyway despite being told by a shift leader that she needed to look after her own babies … After the death of the third or fourth baby it was generally noted that she (Lucy Letby) was involved in each case. This was the only point that the NNU staff observed. At that point, I did not consider that she was the cause of the issues and I thought that her involvement might just have been a coincidence.”¹⁰⁷
Ms Vicky Blamire, a band 4 nurse, commented:
“It wasn’t until finding out about more and more fatalities that questions were asked about which members of staff were present at the time as this would have had a big impact on their mental health. Hearing Lucy’s name with every occasion made me feel very uncomfortable as she didn’t show any kind of emotion. I remember feeling very shocked and confused as to why she didn’t seem to be upset. This was very unnerving.”¹⁰⁸

Deaths on the unit

Dr Gibbs, then the most experienced and longest serving of the paediatricians, said in evidence that in the 20 years he had worked at the Countess prior to 2015, there might have been up to four or so neonatal deaths each year, although one year there had been no deaths. In the three to four years immediately before 2015, he recalled that there had been either two or three deaths each year.
In the years preceding 2015, the number of deaths on the neonatal unit was consistently low. The number of deaths against admissions from 2010 to 2014 were as follows:¹⁰⁹
- 2010: 1 death; 422 admissions
- 2011: 3 deaths; 514 admissions
- 2012: 3 deaths; 556 admissions
- 2013: 2 deaths; 460 admissions
- 2014: 3 deaths; 557 admissions.
In 2015, there were eight deaths on the unit from 468 admissions. Letby was charged with and convicted of murdering five babies – Baby A, Baby C, Baby D, Baby E and Baby I – between June and October 2015. She was also convicted of attempting to murder three babies: Baby B, Baby F and Baby G.
In the first six months of 2016, another five babies died. Letby was charged with and convicted of murdering two babies: Baby O and Baby P. She was also convicted of attempting to murder four babies: Baby K, Baby L, Baby M and Baby N.
Because of the increase in deaths on the neonatal unit, it was downgraded to a Level 1 unit in July 2016. The same month Letby was moved from the neonatal unit. The consultant team did not change. The next death of a neonate at the Countess was in September 2019.¹¹⁰ There have been no deaths on the neonatal unit since then.
Professor Sir David Spiegelhalter OBE, Emeritus Professor of Statistics at the University of Cambridge, gave evidence to the Inquiry. He said that the probability of a neonatal unit experiencing eight deaths in 2015 was 0.008; that is, there was a less than 1 in 100 chance of that number of deaths happening by chance. It followed that eight deaths did not render the neonatal unit an outlier in neonatal mortality rates, in statistical terms. He expressed surprise at the consistently low level of deaths in the preceding five years (from 2010 to 2014). He pointed out that the increase from two or three deaths a year to eight in one year called for an investigation.¹¹¹
It is to the events of 2015 that I now turn.

Footnotes

* The structure has now changed.

Endnotes

Chapter 1

Background

Chapter 3

June 2015: Baby A, Baby B, Baby C and Baby D

Cookies on The Thirlwall Inquiry

Chapter 2. The neonatal unit, 2015 to 2016

Contents

Divisional structure

Women and Children’s Care Governance Board

Staffing levels: Nursing

Nursing team

Doctors

Workload

Relationships in the neonatal unit

Relationships with midwives

Relationships between nurses and senior management

Letby

Training

Work and appraisals

Morphine infusion error, July 2013

How Letby was perceived by her nursing colleagues

Deaths on the unit

Footnotes

Endnotes