Chapter 5. August to September 2015: Baby E, Baby F, Baby G and Baby H

Baby E and Baby F

Mother E and F: “We found out we were having twins, which was – it was a miracle … we were ecstatic. It didn’t feel real. We were very, very happy.”¹

Baby E and Baby F were identical twins born by caesarean section at 29 weeks and 5 days’ gestation. Both twins were born in good condition, weighing 1.327 kilograms and 1.434 kilograms respectively. Mother E and F told the Inquiry: “Everybody that we came into contact with said how well they were doing and they were doing way better than what, you know, they were meant to be doing for their gestation that they were born at. Child E was actually breathing for himself, he was on no support. Child F, he needed a little bit of extra support but that was explained to us.”²

Baby E

On 3 August 2015, Parents E and F had spent all day with their newborn sons. Both parents had skin-to-skin contact with Baby E; Mother E and F described him as “thriving”.³ Mother E and F informed the Inquiry that, on the evening of 3 August 2015, she went to the neonatal unit to bring expressed milk to Baby E. When she entered the corridor, she “could hear screaming and crying, and it was a shock”. She said: “I’d never heard a baby cry like that. And then I walked into the room and I realised it was my baby. And I went to him, and he had blood around his mouth and I was just shocked.”⁴
Mother E and F said Letby was in the nursery room between Baby E’s incubator and the workstation, shuffling papers around.⁵ She said:
“I asked Lucy Letby why there was blood around his mouth, why he was bleeding. She was quite dismissive and said, ‘It’ll be the feed tube rubbing the back of his throat, and that’s where the blood will have come from. But I’ve contacted the registrar, and … he’s on his way. Go back … you go back to the ward and if there’s any problems I’ll ring for you.’”⁶
Mother E and F said, and I accept, that Letby’s behaviour towards her during this incident was different from previous occasions. She told the Inquiry that previously Letby had been kind and looked her in the eye; however, on this occasion, “she seemed really abrasive and didn’t make eye contact with me”.⁷
Mother E and F followed Letby’s instruction and went back upstairs to the post-natal ward. She told the midwife what she had seen. She also phoned her husband at 21:11 because she “knew there was something not right”.⁸
Dr Harkness, the paediatric registrar, was on the night shift in the main children’s ward. He was bleeped by Letby and went across to the neonatal unit. In his written evidence to the Inquiry, Dr Harkness described being asked by Letby to review Baby E, as Baby E had suffered a vomit with blood. Approximately half an hour later, Baby E developed sudden, substantial bleeding. Dr Harkness, who is now a consultant paediatrician, said: “I noted this to be unusual. This was then followed by a further episode of substantial bleeding which I commented to be ‘out of nowhere’ and something I had not seen before or since.”⁹ Dr Harkness described seeing a colour change over the abdomen with “purple and pale patches”.¹⁰ The only other time he had seen such patches was in the case of Baby A.
Dr ZA was called and arrived on the neonatal unit. Baby E suffered a sudden collapse. Dr ZA, Dr Harkness and the nurses began resuscitation.
The midwife to whom Mother E and F had spoken earlier came to her room and asked her to contact her husband and tell him to come to the hospital. Mother E and F went down to the neonatal unit and could see the team working on Baby E. A member of staff asked if she wanted Baby E to be christened.¹¹ Mother E and F said: “I actually don’t believe that I would have — 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.’”¹² Mother E and F remembered sitting outside for some time, and then a nurse came out and invited her to go in. She described holding her son’s hand and said: “I was just talking to him, telling him everything was going to be okay and all the fun that we were going to have when we got home.”¹³ She said that Baby E was christened, and, when it became clear that they could not save him, Dr ZA asked to stop working on him. Baby E died at 01:40 on 4 August 2015. In August 2023, Letby was convicted of his murder.
On reflection, Mother E and F believed that she had witnessed “[a]n interrupted attack”. She added: “I think I caught her off guard. Something had happened to him for him to be bleeding. Stable babies don’t bleed.”¹⁴
Mother E and F subsequently saw Baby E’s medical records and learnt from the criminal trial “that the notes had been changed to suit a different narrative of when Child E’s bleed started”. In Baby E’s nursing notes, Letby wrote: “[A]t 22:00 large vomit of fresh blood. 14ml fresh blood aspirate obtained from NG [nasogastric feeding] tube. Reg Harkness attended.” There was no reference in the notes to the incident described by Mother E and F at about 9pm. Mother E and F obtained a copy of her own phone records, which demonstrated that her memory was accurate about the timing of her exchange with Letby, before she had telephoned her husband. I accept Mother E and F’s evidence about her experiences that evening. I accept that Letby omitted from the notes Baby E’s distress and the blood on his mouth at about 9pm. She also omitted Mother E and F’s visit to the neonatal unit.
At the time of these events, Parents E and F both believed that Letby was doing what was best for Baby E. After he died, Letby bathed him and chose the clothes that he was to be buried in. Letby also made a memory box for Baby E. Mother E and F described it as “painful” to know that all the contents had either been created or touched by Letby.¹⁵ She told the Inquiry that Baby E’s memory box was created without her consent or prior knowledge: “[T]he memory boxes, they’re really important, but we didn’t know that that was happening. You know, we hadn’t given any consent for that to be done.”¹⁶
At the time Baby E died, Dr ZA thought that he had died of necrotising enterocolitis (NEC), a serious condition of the intestines that mainly affects premature babies. She spoke to Baby E’s parents about a post-mortem. Mother E and F said that Dr ZA had “mentioned a post-mortem”. She said: “I think it was my husband who asked what would that be able to tell us? And she [Dr ZA] said well, she didn’t think that that would … because, you know, she believed he’d died from NEC.”¹⁷ Dr ZA did not remember the conversation as well as the parents did, but she accepted their account that she had said a post-mortem would not add anything. She said in evidence that an additional reason for Baby E not having a post-mortem was because she “knew that Child E’s parents were already devastated and didn’t like the idea of a postmortem”. She said: “I didn’t want to do anything that made what was already an awful situation for them any harder. So it was the wrong decision but it was done with the best of intentions.”¹⁸ She spoke to the coroner’s officer, who spoke to the assistant coroner, who accepted her diagnosis and decided against a post-mortem.¹⁹
Dr ZA stated she was “surprised at how quickly he deteriorated”; however, she did not link Baby E’s death to the three June 2015 deaths because she “felt that there was an appropriate medical explanation [for Baby E’s death] at that time”.²⁰ Baby E had an abdominal X-ray in the early hours of 4 August 2015. In her evidence to the Inquiry, Dr ZA acknowledged that she had not realised the significance of the absence of signs of NEC on the abdominal X-ray. She explained that, when she had looked at Baby E’s X-ray, it had looked relatively normal, but that does not exclude an NEC diagnosis. She went on to say: “It was reviewing Child E’s death in hindsight I thought that if the NEC was severe enough to cause him to die, then there should have been signs on the X-ray, but I didn’t make that connection at the time.”²¹ Dr ZA acknowledged that she “should have been more curious” with regard to the X-ray and whether the images amounted to an NEC diagnosis.²² Because Dr ZA did not carefully review the X-ray, she was satisfied, when she should not have been, that her diagnosis was correct and advised the parents and the coroner accordingly. Mr Harvey would later, reasonably, rely on the coroner’s view in support of the view that this was a natural death.²³
Parents E and F decided not to have a post-mortem. Mother E and F explained:
“I think trying to make an informed decision when you’ve got your child that’s died in your arms on whether you want him to have a postmortem is — it’s an impossible decision to have to make and I couldn’t — I couldn’t make an informed decision at that time. So I feel that it’s unfair to ask a bereaved parent whether they want that to happen for their child, because of course you don’t.”²⁴

Mother E and F asked: “[I]f there was nothing on Child E’s X-ray to say there was any signs of NEC, why was the postmortem not, you know, mandatory? Why was it left for me to make that decision?”²⁵

Dr Harkness accepted in his statement that, at the time, he too had thought that NEC was the cause of death. He added, however, that, with the knowledge and experience he has now, and in his current position as Named Doctor for Safeguarding, were he faced with a similar circumstance today, he would initiate a SUDIC procedure, which would involve a post-mortem. However, he told the Inquiry: “I do not think that decisions to undertake these procedures in inpatient deaths [were] common at the time, although in light of the events at the Hospital it has affected the practice in my health board and I am sure it has affected practice elsewhere.”²⁶ His observation about the general view at that time is correct. I deal with the question of SUDIC in Chapter 12.
Baby E died on Dr Wood’s last day at the hospital as a GP trainee. Dr Wood said: “[I]n relation to Child E’s death ‘it really seemed to come out of the blue’ – Child E had seemed well leading up to this and wasn’t ‘on the radar’ as a child of particular concern.”²⁷ In his statement to the Inquiry, Dr Wood went on to say: “I was worried about the number of deaths only because it was suggested that they were more numerous than normal and perhaps occurring in babies who seemed to be doing well.”²⁸
Mother E and F also spoke of how sudden and unexpected Baby E’s death was. She shared in oral evidence that “a couple of hours earlier we had two thriving little boys”. She added: “[I]n the space of a couple of hours, it had all been taken. And our world had just [spun] upside down and nothing felt right.”²⁹
She told the Inquiry that, after Baby E’s death, Parents E and F “went into see Child F, and Child E was still in his incubator”. Mother E and F said: “[I]t took my breath away in that moment. And it was actually Lucy Letby, and I said, ‘He’s still here’ and she said, ‘You haven’t told us to take him’, but then I didn’t know that I was meant to — I didn’t know what was meant to happen.”³⁰ Letby’s remark to a bereaved mother was shockingly cold and unfeeling.
Nurse W had a recollection of Baby E from her shifts on 29 July 2015 and 3 August 2015. She gave evidence that, when she had left Baby E on 3 August 2015, he was clinically well. He died the next morning. Recalling coming in to work on 4 August 2015, she said: “She [Letby] couldn’t wait to tell me and it was not easy news to walk into first thing in the morning.” Nurse W felt “bombarded” by Letby.³¹ Ms Taylor similarly described Letby informing her of another child’s death, saying that “it was almost in a way where she was excited to tell me almost like a gossip — in a gossipy manner”.³²
Letby was convicted of Baby E’s murder.

Baby F

Baby F was born in good condition and, at 1.434 kilograms, slightly heavier than his twin brother. When admitted to the neonatal unit shortly after his birth, he had a low blood glucose level of 1.9 millimoles per litre. The following day, his blood glucose rose to the very high level of 15.1 millimoles per litre. At 03:40 on 31 July 2015, manufactured insulin was administered; he responded well to the insulin and his blood glucose dropped within an hour to 8.7 millimoles per litre. Letby was found guilty of the attempted murder of Baby F. Professor Peter Hindmarsh, Professor of Paediatric Endocrinology at University College London Hospital, who gave evidence at the criminal trial about Baby F and Baby L, said that Baby F’s blood test results demonstrated that exogenous insulin had been administered to Baby F over a 17-hour period. The jury found Letby had added insulin to two total parenteral nutrition (TPN) bags. The two bags were supplying liquids to Baby F overnight on 4/5 August 2015 and on 5 August 2015 respectively.
During the night of 4/5 August 2015, Dr Harkness was called to attend to Baby F. As Dr Harkness noted in his statement to the Inquiry, he was “concerned about both Child F’s increased heart rate and low blood sugars” and he discussed this on the phone with Dr Gibbs, the consultant on call.³³ Dr Gibbs said that he had examined Baby F at around 8.30am on 5 August 2015 and noted he had low blood sugar levels and suspected that he had an infection. The low levels persisted, despite Baby F being given extra sugar.³⁴ Dr Gibbs described this as “unusual”.³⁵ Thus, blood samples were taken at 17:56 on 5 August 2015, while Baby F’s blood glucose was low, and sent to Liverpool Clinical Laboratories at Royal Liverpool University Hospital for analysis.³⁶ When the intravenous feeds were stopped and the TPN bag was taken down, the blood sugars started to increase.
Mother E and F recalled that she and her husband were in the accommodation on the neonatal unit waiting for news of a transfer to a hospital nearer to their home. She said: “Nurse T come and knocked on the door, and said, ‘I think you need to come in to Nursery 2, Child F is experiencing really rapid, fast heart rate’, and in that moment I just thought: not again. This simply cannot be happening to us again.”³⁷ Mother E and F said Dr Gibbs had come to review Baby F and “told me that Child F had an infection in the long line of his leg, and moving the long line in his leg, and setting him on a course of antibiotics would rectify things”.³⁸ She said: “I didn’t even know he’d been tested for insulin. Insulin was never mentioned to us at the time.”³⁹

The laboratory tests

Liverpool Clinical Laboratories performed an insulin and C-peptide test. Analysis of Baby F’s blood samples showed low C-peptide to insulin. This was very significant, but, by the time the results were received on 12 August 2015, Baby F was stable and his glucose levels were normal.⁴⁰
The results of the test (low C-peptide to insulin) were recognised as important. Baby F had an insulin level of 4,657 picomoles per litre and insulin C-peptide levels of 169 picomoles per litre. Ms Heather Wilshaw-Jones, Senior Clinical Scientist at Liverpool Clinical Laboratories, telephoned the Trust to speak to the “Countess of Chester Biochemist”.⁴¹ Ms Wilshaw-Jones did not have any clinical details and did not know whether insulin had been prescribed for Baby F. The note made by Ms Wilshaw-Jones of her call reads: “Low C-Peptide to insulin. ?Exogenous – suggest send sample to Guildford for exogenous insulin.”⁴² This was serious. Exogenous meant external. What the result showed was that the blood sample contained insulin that had been administered from an external source, rather than being manufactured by the body. In other words, the baby had been given insulin, which had not been prescribed to him.
It seems that the results were phoned through to the ward by someone in the laboratory at the Countess. There is no evidence that there was any urgency expressed or that there were any concerns. But the evidence is that the laboratory only telephones the ward if there is something significant in the result.⁴³ It is not known who received the phone call or passed on the information. There is a note of the blood results in the medical note written by Dr Lyddon on 13 August 2015. The annotation shows, by vertical arrows, that the insulin level was high and the C-peptide level was low. Dr Lyddon’s entry in the medical notes recorded the result and her subsequent discussion with Dr ZA thus:

“Hypo screen results

Cortisol 364

Insulin 4657 ↑

Insulin C-Peptide <169 ↓

C-Peptide / Ins 0 ↓

D/W Doctor ZA – insulin high, c-peptide low – unusual for hypoglycaemia. As now well and sugars stable no further ix”.⁴⁴

In oral evidence, Dr Anna Milan, Principal Clinical Scientist at Liverpool Clinical Laboratories, explained the science behind Baby F’s results. She said:
“[W]hen insulin’s formed in the body it’s formed from a precursor, so it’s a molecule that contains insulin … So once it’s cleaved in the body you get one C-peptide and one insulin. So in health it’s equimolarly produced, so equal portions, and insulin has a very short half-life, whereas C-peptide has a longer half-life, so it hangs around for longer … the normal ratio in health should be that C-peptide to insulin has a ratio of about 10 to 1, sometimes that can be 5 to 1, depending on metabolism. In this case it was the other way round. So insulin is extremely high with an undetectable C-peptide. So that points to the fact that this wasn’t produced by the body and so the primary differential is exogenous insulin administration.”⁴⁵
Dr Milan explained that the insulin C-peptide was undetectable and was recorded as “<169” because this is the lowest quantifiable measurement.⁴⁶ She asserted that Baby F’s results “warranted a phone call to Chester … to expedite that information to the clinical team”.⁴⁷ Dr Milan stated that the results “would be considered a safeguarding issue”.⁴⁸
There have been some suggestions from different quarters outside the Inquiry that the testing carried out was in some way defective. The evidence to the Inquiry was to the contrary effect. Dr Milan explained first in writing and then clearly in oral evidence that the quality assurance process at the laboratory enabled her to be sure the test results were accurate. She stated: “We wouldn’t have even measured the sample if we weren’t sure that the analyser was performing appropriately that day. And then with the results, we have to double-check that the — it’s a quality control procedure before we even release a result on to an electronic system to be communicated.”⁴⁹ This is what is to be expected of a laboratory providing such an important service. There is no reason to think that the machines were not properly calibrated or that there was any error in the process. Immune assay tests of this type are widely used. They are relied upon in every hospital in the land. External criticism has been made that the test does not distinguish between exogenous and endogenous insulin, but that is to overlook the other part of the test – the use of the C-peptide – which gives a robust basis to say that the insulin is exogenous.⁵⁰ None of the Core Participants sought to explore, still less challenge, any of Dr Milan’s evidence.
Dr ZA said in evidence that the results indicated that something unexpected was happening, as “the blood results looked as if Child F had been given exogenous insulin, which is an insulin as a medication”.⁵¹ She explained that, if insulin was produced naturally in the body, you would expect to see significantly more C-peptide than insulin.⁵² She recalls that she checked and established that no other child on the neonatal unit had been prescribed insulin, making accidental administration unlikely. She dismissed the idea of deliberate administration of insulin:
“[T]he idea that someone could be doing it deliberately just seemed so fantastical and unlikely that that couldn’t possibly be what had happened. With neonatal blood samples, because they’re so small and often difficult to obtain, we do get unusual results from time to time, and our normal practice if something is outside of what we would expect is to repeat them. We obviously couldn’t repeat the bloods at this point because Child F was well with a normal glucose level, so we wouldn’t be able to repeat them.”⁵³
Dr ZA did nothing to check whether she was right to dismiss the possibility of deliberate administration of insulin. She did not contact the laboratory at Chester, or the laboratory at Liverpool. Nor did she speak with any colleagues. Nor did she mention it to Dr Brearey, even though she knew by that stage that he had concerns about the increased mortality on the neonatal unit. As for a further test in Guildford, the baby was now stable and no further test was deemed necessary.
Dr ZA was completely candid: “At the time, I just dismissed the idea of someone deliberately administering insulin because it just seemed so impossible.”⁵⁴ She later said, when asked if she had considered whether there was something unnatural, “It crossed my mind and I rejected it.”⁵⁵ She recognised she had “made the wrong decision”.⁵⁶ Dr ZA reflected: “I deeply regret that that is how I interpreted things both for Child E and F’s parents and for all the babies that happened subsequently.”⁵⁷ Unlike many who have given evidence, Dr ZA, from the outset, acknowledged her own failings. Long before the Inquiry, she had written to Parents E and F apologising for her errors in respect of both children. The insulin administration ultimately came to light because, when the police were alerted in 2017, she remembered the insulin results in August 2015. She had understood them at the time. Dr ZA explained in oral evidence that this was troubling her when she was on leave in mid-2017. She said: “I had something in the back of my mind nagging about Child F’s results and the fact that at the time I’d dismissed the possibility of deliberate harm, but now, based on what we were thinking, that didn’t seem so impossible any more.”⁵⁸ On 6 June 2017, Dr ZA sent an email to Dr Brearey raising her concerns about insulin.⁵⁹ Dr Brearey was going through the medical notes of all babies in the relevant period. He found the insulin results in Baby F’s notes and the police were informed.
Mr Harvey said in his written statement for this Inquiry, and then in his evidence, that he should have been told about this important result.⁶⁰ I agree with him. He said it would have affected the decision about whether to call the police. It should have led immediately to a call to the police.
Dr Gibbs noticed the result for the first time when he was asked to provide a statement to the police in the investigation into Letby. He checked the significance of the C-peptide results, which meant that it “was likely to be insulin that had been injected into the baby”.⁶¹ Dr Gibbs had missed the results when he reviewed Baby F’s case during the Silver Command investigation in July 2016 (see Chapter 15), but his role there was to look at babies who were transferred out of the neonatal unit following an unexpected collapse.⁶² Dr Gibbs explained: “But Child F was transferred out when he was entirely well because the Family lived outside West Cheshire and he was going back home. So as soon as we saw that, we stopped looking at him in the review.”⁶³
To the Inquiry, Dr Gibbs expressed the view that the failure to see and act upon the insulin results in Baby F’s notes was a collective failure by all the consultants. Other consultants said that too. Whilst it is true, as all the consultants acknowledged in evidence, that the results were there and anyone could have read them, no consultant at the Countess other than Dr ZA had any reason to look at the notes of Baby F at that time. Baby F was transferred to a different hospital shortly after the results were entered into the notes. I do not accept that there was a collective failure here.
Mother E and F said: “I realised in the criminal trial that the insulin reading was there and it was seen and nothing was done. That could have been an end to this whole horrendously sad turn of events, but it wasn’t.”⁶⁴
She said that what had happened to her sons had changed the course of the family’s life completely, stating: “[W]e’ve had to try and grieve in so many different ways. We tried to grieve for Child E … We had to grieve for the life that we thought we were going to have with Child F, with his learning difficulties.”⁶⁵

Serious Incident Panel, 13 August 2015

On the morning of 13 August 2015, Ms Millward emailed Mr Harvey, Ms Kelly and others to inform them that the death of Baby E was to be considered by the Serious Incident Panel later that day. She described Baby E’s death as: “Unexpected neonatal death of a twin aged [redacted] days (NNU).”⁶⁶ It is surprising that Ms Millward did not alert the recipients of the email to the fact that this was now the fourth death on the neonatal unit in a short period, nor did she establish and share with Mr Harvey and Ms Kelly that this was an unusually high number of deaths compared with previous years. She should have done both. It is equally surprising that neither Ms Kelly nor Mr Harvey connected the meeting held on 2 July 2015, which had discussed Baby A, Baby C and Baby D and had been attended by Ms Kelly, and so failed to connect the deaths of the four children themselves.
The Serious Incident Panel meeting was held on the afternoon of 13 August 2015. Present were Mr Harvey, Ms Kelly and Ms Sarah Harper-Lea (Head of Legal Services) along with Ms Millward. There are no minutes of the meeting except for a very brief note on the Datix form.⁶⁷ In oral evidence, Ms Millward explained that Baby E’s death was not reported as a Serious Incident because, at the time, “the feedback that was received from the unit was again that there was clinical reasons that would have contributed to the death”.⁶⁸ Mr Harvey was satisfied that, although the death of Baby E was unexpected, there were no apparent concerns from the medical staff (Dr ZA having concluded that Baby E had NEC). He took comfort from the fact that the coroner was content. There was no effective review, and so Baby E’s death was not reported to StEIS.⁶⁹
This outcome demonstrates a flawed approach to review. It is clear that the approach of those at the meeting was to look only at the case in front of them, that of Baby E. They were all satisfied that there was a natural cause, so they saw no reason to look further. That having been said, it had been Ms Kelly’s view at the meeting in July 2015 that an eye should be kept on neonatal unit mortality in light of the three deaths. She should, as a minimum, have reminded the other people at the August 2015 meeting that this was the fourth death in just over two months, and that she was keeping an eye on neonatal mortality. Given the clear finding of a natural cause for the death of Baby E, a referral to StEIS was not considered. The fact that this was the fourth death was not even recorded at that meeting.
Ms Millward agreed that, if the death had been reported to StEIS, it would have prompted a comprehensive review of the neonatal unit’s practices.⁷⁰ As noted by Dr Brearey and set out in Chapter 4, an additional benefit of a Serious Incident Investigation is that investigators meet the parents, who have an opportunity to say what they are concerned about.⁷¹ Had investigators spoken to Mother E and F, the disparity between what she had seen and heard and what Letby had written would have been obvious. The truth about the earlier part of the evening would have been known, including what Mother E and F had seen of the condition of her child. All that having been said, the StEIS report in respect of Baby D (see Chapter 4) led to no external comprehensive review. Given Dr ZA’s confidence in her view of the cause of Baby E’s death, it is far from certain that a StEIS report would have made any difference.
In oral evidence, Mother E and F said she was not aware of the Serious Incident Panel meeting regarding Baby E’s death. She pointed out that the date of the meeting, 13 August 2015, was the day of Baby E’s funeral.⁷²
It was noted on the Datix form that the death of Baby E would be discussed in a neonatal mortality review.⁷³ This did not happen, because, at the meeting at which Baby E was to be considered, there were three other babies to be reviewed and there was not enough time to consider Baby E. The dates for these meetings were fixed at the beginning of the year. The number of meetings scheduled was assessed by reference to the number of deaths in the previous year; there had been three deaths in 2014. By August 2015, there had already been four deaths on the neonatal unit. The pre-arranged meetings could not accommodate them all. As a result, some cases were not considered in that forum. No further meeting was organised. It is likely that, as with the meeting of the Serious Incident Panel, NEC having been the diagnosis, it was thought there was no need.
Dr Brearey completed his own review of the death of Baby E, dated October 2015. He recorded the likely cause of death as “a perforated bowel secondary to NEC”.⁷⁴ He agreed in evidence that Mother E and F had important information to give about the death of Baby E. He said: “[I]t would have been really helpful to have the parents there but it just wasn’t the process at the time.”⁷⁵ He recalled speaking to Dr ZA about Baby E and that she was satisfied that the cause of death was NEC.
The deep-rooted belief held by many that nurses do not harm babies manifested itself in Dr Brearey’s thinking at the time. In August 2015, despite being concerned about the deaths and being aware of Letby’s presence, Dr Brearey explained it was “quite firmly in my mindset that these were natural and this is me just being paranoid”.⁷⁶ He was not alone in this. No one else thought Letby or anyone on the unit was responsible for the deaths.

Clinical Effectiveness Group meeting

Baby E’s death was referred to and discussed at the Cheshire and Merseyside Neonatal Network Clinical Effectiveness Group meeting held on 12 November 2015, attended by Dr Brearey and Ms Powell.⁷⁷ It appears that the three June 2015 deaths of Baby A, Baby C and Baby D had also been noted for discussion at the earlier meeting on 16 September 2015.⁷⁸
Dr Subhedar was the Clinical Lead for the Cheshire and Merseyside Neonatal Network (the Neonatal Network). In oral evidence to the Inquiry, he explained that the Neonatal Network was one of three locality networks in the overarching Operational Delivery Network across the NHS North West region. There were nine neonatal provider units, including the neonatal unit at the Countess.⁷⁹ Dr Subhedar chaired the Clinical Effectiveness Group, which met every two months.⁸⁰ He explained: “The primary role of that group was sharing and learning, really. Learning from Incident Reviews and Mortality Reviews that were conducted by neonatal unit providers and sharing best practice.”⁸¹
It was Dr Brearey’s recollection that, after the meeting on 16 September 2015, he told Dr Subhedar “that we had had some more deaths in addition to the three that were discussed in the meeting” and that the Countess was “having more [deaths] than expected”.⁸² He did not tell him about the association with Letby.⁸³ He said that Dr Subhedar advised him to keep the Neonatal Network informed. Dr Subhedar recalled this conversation but said that it had taken place after the Clinical Effectiveness Group meeting on 21 January 2016.⁸⁴ Dr Subhedar also recalled that it was during this conversation that Dr Brearey asked him (as he undoubtedly did) to be involved in the Thematic Review of Neonatal Mortality.⁸⁵ The precise date of the conversation does not matter. What matters is that Dr Brearey told Dr Subhedar about the increased mortality rate and asked him to become involved in a review.

Referral to CDOP

Baby E’s death, as well as being referred to the Neonatal Network, was also referred to the CDOP on 5 August 2015 by Dr ZA.⁸⁶ It appears that there was a meeting on 18 December 2015,⁸⁷ at which the cause of death was recorded as ‘Prematurity, Necrotising Enterocolitis’ and no recommendations were made.
Ms Sharon Dodd, Paediatric Liaison and CDOP Nurse Representative, Cheshire and Wirral Partnership NHS Foundation Trust, received the CDOP Form A notification forms (see also Chapter 12). She gave oral evidence that she had a good working relationship with Dr Rajiv Mittal, Designated Doctor for Safeguarding and Child Deaths, Integrated Care Board (ICB). Ms Sharon Dodd stated they would inform one another of child deaths at the Countess depending on who had received the Form A first. Ms Sharon Dodd thought that she and Dr Mittal may have discussed in around September 2015 that there had been three or four deaths on the unit and that it was tragic to have those deaths; however, the pair did not discuss any concerns or scrutinise the deaths.⁸⁸ Her evidence was that “the information that I received didn’t alert me to any concerns around those deaths”.⁸⁹ She would have expected Dr Mittal to have told her if he knew there were concerns at the time.⁹⁰
Dr Mittal had a similar recollection to Ms Sharon Dodd of their conversation. He gave evidence that he “knew that the number of deaths [were] more because of the notification forms”⁹¹ and that “the number of deaths in [the] Countess were much more than what we would normally expect in a year”.⁹² Despite this knowledge, and being based on the same corridor as the other consultant paediatricians, Dr Mittal did not approach the clinicians to ask about the increased number of deaths. He accepted that, “in hindsight”, he “should have explored these more”.⁹³ Given his role, he should have asked some questions about the increased number of deaths. I deal separately with the multitude of failures of safeguarding in Chapter 12.
Dr ZA gave evidence that, at some point after Baby E’s death, the consultants had a discussion about the number of deaths. She said: ‘[T]here was quite a high level of concern that we’d had four deaths at this stage, and very much a worry about what were we overlooking in terms of medical care, environment, why — why had this happened.”⁹⁴ Dr ZA could not recall any concerns of deliberate harm being raised at this stage.⁹⁵
Ms Anne Murphy (Lead Nurse for Children’s Services) told the Inquiry that, after Baby E’s death, she had informed Ms Jane Evans (Head of Nursing, Urgent Care Division) about “a series of infant deaths”. She had informed her it was “slightly unusual for the neonatal unit to have a spate of deaths all at once”.⁹⁶ It was not slightly unusual; it had not happened before.
Ms Karen Rees (Moore), Head of Nursing, later Associate Director of Nursing, Urgent Care Division, had replaced Ms Evans in the role by September 2015. Ms Rees stated she became involved in discussions around mortality when the Brigham Review was received by QSPEC in December 2015.⁹⁷ Ms Rees characterised the communication of concerns as “a little bit cloak and dagger” and thought she should have been informed sooner.⁹⁸ She thought that she had been left out of things by the senior managers. Her predecessor had been informed of the deaths and I see no reason for the same information not to have been passed on to Ms Rees. If the information was not passed on, that was an error by Ms Anne Murphy and by Ms Powell, both of whom understood the position. Ms Powell was well aware, at the time when Ms Rees joined the division, that there had been an increase in neonatal deaths. Whether or not there had been a failure to pass on the information by Ms Powell or Ms Anne Murphy, Ms Rees was right to say this was something she should have been told about shortly after taking on her new role in September 2015.

Board meeting, September 2015

On 1 September 2015, there was a public meeting of the Board of Directors.⁹⁹ The minutes record that the Medical Director (Mr Harvey) presented the hospital’s mortality report to the Board.¹⁰⁰ However, there is no reference in the minutes to the increase in mortality on the neonatal unit, which had now reached four deaths in a period of just over two months. The three June 2015 deaths had also not been mentioned at the Board meeting on 7 July 2015.
The minutes of the meeting record: “Mr Harvey now personally reviews every death in the Trust and then refers cases for further review where appropriate.”¹⁰¹ That statement was important and duly minuted. The minutes were not challenged until 2024, and then by Mr Harvey only in the context of this Inquiry. He said in evidence that the minutes were wrong and should have referred to every adult death. If the public were to understand that Mr Harvey was reviewing all deaths except those of children, that should have been said in clear terms.
Mr Harvey was confident, he said in evidence, that there was a process in place for reviewing child mortality¹⁰² – for example, mortality reviews, MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) and the like – but they are nothing to the point. There is no evidence of any process which put the mortality data for children and babies before the Board of the hospital, and there is no evidence that anyone noticed. Ms Kelly accepted in evidence that, whereas adult mortality was reported to the Board, the same scrutiny was not applied to neonatal deaths.¹⁰³ It was a failing of the governance process that the Board did not routinely receive information about neonatal deaths in 2015/16.
I acknowledge elsewhere in this Report that paperwork in the NHS is unnecessarily onerous, but the Board of a hospital should know about the deaths of babies and children. The contrary is unarguable. The numbers are, as I was often reminded, very small. That is not a reason to ignore them and all the more reason to be aware of an unusual increase.
I note that, at the same meeting, the Board specifically discussed the mix of expertise on the neonatal unit in light of recommendations made by Dr Bill Kirkup CBE in his report on the University Hospitals of Morecambe Bay NHS Foundation Trust. This was obviously the moment to say in public, if it were the case, that ‘all the deaths in the hospital’ did not include those of babies and children.
Mr Harvey and Ms Kelly both knew there had been a marked increase in deaths on the neonatal unit, and neither brought it to the attention of the Board when discussing the unit. It was less than three weeks earlier that they had been reviewing the death of Baby E, and both knew about the deaths of Baby A, Baby C and Baby D in June. The Board should have been told. That they were not told is evidence, at least, of a lack of interest in infant mortality and/or of a desire to keep unwelcome news under wraps in the hope that an explanation would come to light which would reassure the Board that there was nothing to worry about.
At the Board meeting on 1 September 2015, the Board was told that the number of staff who had received safeguarding training was under expected levels.¹⁰⁴ Whilst this was presumably the case for the hospital as a whole, it was not the case in respect of children, in that all Group 3 staff (those who had regular contact with children and their families, such as nursing and medical staff on the neonatal unit) received training in safeguarding. Ms Paula Sindall (née Lewis), a specialist safeguarding children’s nurse (band 7), explained that training was monitored by staff managers to achieve compliance targets of 80%, as set by the Clinical Commissioning Group. She set out in her evidence that Group 3 staff both attended annual face-to-face training and completed additional e-learning.¹⁰⁵ In the event, no questions emanated from the Board about safeguarding children.

Baby G and Baby H

Between 7 and 27 September 2015, two more babies, Baby G and Baby H, suffered a number of unexpected collapses while Letby was on duty.

Baby G

Baby G was born in Arrowe Park Hospital at 23 weeks and 6 days’ gestation, weighing 535 grams. She spent approximately 11 weeks at Arrowe Park Hospital.
Mother G said in evidence:
“Our baby was taken to the intensive care part of the Neonatal Unit of Arrowe Park Hospital. She was ventilated and had several intravenous lines. She was absolutely tiny and her skin was almost see-through, but I felt so much love for her … Our daughter had many brain scans at Arrowe Park Hospital, and we were told they were looking good. I could see her growing and made sure I was present as much as possible so we could bond. She was our little miracle, a gift from God. We were so happy to see her improving.”¹⁰⁶
On 13 August 2015, she was transferred to the Countess in a stable condition.
Mother G explained:
“At first, our daughter continued to improve. She was doing so well. She was smiling, grabbing her dummy with her hand, drinking from her bottle, recognising and responding to our voices. She had a cheeky little smile which I loved. We were coming up to her 100th day since birth … and the nurses on the Unit had prepared balloons, cake and a banner to celebrate our daughter’s 100th day, which was very exciting. We were told that she was doing well and that it wouldn’t be long before we would be able to take her home.”¹⁰⁷
Dr Brearey reviewed Baby G on 6 September 2015 in Nursery 2 and confirmed she was stable and improving, and preparations for her discharge home continued.

Collapses

Nurse Z was the designated nurse for Baby G for the night shift of 6/7 September 2015. Ms Ailsa Simpson was the shift leader and Dr Alison Ventress was the registrar on duty. Letby was working on the night shift, allocated to a child in Nursery 1.
Baby G suffered repeated collapses in the early hours of 7 September 2015 after a large projectile vomit at around 2.15am. The vomit was substantial and said to have projected several feet across the room, away from her cot. During subsequent attempts to resuscitate Baby G, 100 millilitres of milk was aspirated from her stomach. The volume of milk taken from Baby G’s stomach, combined with the volume that she had vomited, far exceeded the small volume of expressed breast milk that she had been fed.
Parents G were called in the early hours of 7 September 2015 and were told that their child had vomited and aspirated her vomit. They were told that her blood tests confirmed neonatal sepsis. They were not told that Baby G had collapsed.¹⁰⁸ Father G said:
“The doctors didn’t tell us that on 7 September 2015 our baby daughter in fact had a projectile vomit, with the milk coming out of her tiny little body with so much force that it reached the chairs opposite her cot. They also didn’t tell us that upon aspirating the contents of our daughter’s stomach after her projectile vomit on 7 September 2015, they found she still had around 45 millilitres of milk in her stomach, which was an enormous amount of milk and more than her feed.”¹⁰⁹

He continued: “[I]t was calculated that her projectile vomit of 7 September 2015 that had reached the chair in her room was a distance of 3–4 feet away from her cot, indicating the force of her vomit and the pain she must have felt with the pressure building up in her tiny little body.”¹¹⁰

After initial resuscitation efforts, Baby G was treated for presumed sepsis with antibiotics. The initial sepsis diagnosis was recorded, even though Baby G’s CRP (C-reactive protein) was (at that point) normal and she had no other signs or symptoms of infection. At 15:00 on 7 September 2015, Dr ZA recorded a blood test result in Baby G’s medical records which noted a CRP of less than 1. Dr ZA gave evidence that this result within 12 hours of Baby G’s collapse was not consistent with sepsis causing a collapse.¹¹¹ Dr Brearey accepted in his oral evidence that, whilst at the time it was felt that the blood tests were indicative of an infection, he now accepted a different cause of collapse.¹¹² Mother G informed the Inquiry that Parents G “only found out years later that the blood tests that had been done at the time showed no evidence that our daughter was suffering from sepsis”.¹¹³
Baby G was transferred to Arrowe Park Hospital on 8 September 2015, where her condition improved. While she was there, a brain scan was carried out. Baby G was transferred back to the Countess on 16 September 2015.
On the day shift of 21 September 2015, Baby G was being cared for in Nursery 4, with Letby as her designated nurse. Shortly after a feed at 09:00, Baby G had two large projectile vomits which caused her to stop breathing temporarily. Mother G recalled coming to see her daughter that morning. She was told by Letby to wait in the parents’ room, as Letby had to do some tests on Baby G. After a while, Mother G heard Baby G screaming, so she ran back into the room to make sure that her child was okay. Mother G found “Letby standing by our daughter’s cot, looking sort of puzzled”. She continued: “There was another nurse in the room as well. Our daughter was screaming and looked very red and I saw vomit on her.”¹¹⁴
Baby G was moved to Nursery 1 mid-morning, and Nurse W took over her care. She collapsed again at 15:30. This episode was again put down to sepsis, although, as before, negative cultures were again reported and Baby G’s slightly raised CRP was not considered to support such a diagnosis.
At the time, Dr Brearey was aware Baby G had had a large vomit yet still required an abnormally large amount of gas and fluid to be aspirated from her stomach. However, he did not appreciate the significance of this at the time, and did not tell Parents G about it. He should have done, as he accepted.¹¹⁵ He accepted that the fact that, after large projectile vomits, there was still 100 millilitres of fluid in her stomach was certainly unusual. In 2017, he referred the case of Baby G to the police because it had reached the threshold at which it was appropriate to do so, but he did not have sufficient knowledge to say precisely what had happened.¹¹⁶
Dr Gibbs stated he did not have any concerns or suspicions about deliberate harm at the time of Baby G’s collapses, because he had thought Baby G was an extremely premature child prone to collapse. With hindsight, he reflected: “I feel I was misleading myself.”¹¹⁷ He was. Baby G had been transferred to the Countess in a stable condition. She was now at the equivalent of 35 weeks’ gestation. All the preparations were being made for her to go home. It was a time of celebration. The collapses came, apparently, from nowhere.
Letby was found guilty of attempting to murder Baby G on two occasions: during the night shift of 6/7 September 2015 and on the morning of 21 September 2015. She was found not guilty of a further charge of attempted murder on the afternoon of 21 September 2015.
Baby G suffered profound brain injury from her collapses with lifelong consequences. Mother G described the impact of Baby G’s collapses on their family. She said: “I feel that Lucy Letby has ruined our lives. She has ruined everything. Our daughter needs 24-hour care because of Letby, we don’t know how long she will live and it affects every single minute of all of our days.”¹¹⁸
Mother G said:
“The Countess of Chester Hospital never once told us they had any concerns about Lucy Letby and we didn’t find out until we were informed by the police in 2018 — but even then, we knew no details of what precisely Lucy Letby was accused of having done to our daughter. We only found this out just before the criminal trial of Lucy Letby, which was harrowing. I feel that the Countess of Chester Hospital have covered up what happened to our daughter for years, telling us all this time that our daughter suffered neonatal sepsis, despite there not even being a marker for sepsis in her blood tests at the time.”¹¹⁹
Dr Brearey has been the paediatrician for Baby G since 2015. He was reminded by Mr Baker KC of a time in one of their consultations when he showed Father G the observations for his daughter and told him that they were entirely normal up until the point of the collapse. He was asked whether he was trying to tell Father G something. He said that he could not remember that specifically. He said that, at that time, his focus was still on the deaths:
“I can’t remember whether my suspicion with Baby G was — was very high or I really can’t remember where I was in my mind process about the concerns for her at the time. I certainly wouldn’t have been in a position to or want to mislead any family in any way, certainly not — not her family and — and if I — ever did, I am sincerely sorry for that really.”¹²⁰

He said that he had felt uncomfortable with other families but pointed out:

“[O]nce you share a concern like that with a parent, you are effectively putting your concerns into the public domain before a police investigation has even started which is — is difficult to feel is — is appropriate, you know, I had never been in this situation before. I have always tried to be as honest as I can with any set of parents and if I did mislead them and I was thinking of concerns at that time, I sincerely apologise for that. But that certainly wasn’t anything malicious or intentional.”121

Baby H

Baby H was born at 34 weeks and 4 days’ gestation, weighing 2.33 kilograms. She suffered a series of collapses between 24 and 27 September 2015. Letby was charged with causing her sudden collapses during two consecutive night shifts, at 03:22 on 26 September 2015 and at 00:55 on 27 September 2015. Baby H was being cared for in Nursery 1, with Ms Tomlins as her designated nurse. Letby was also working in Nursery 1, caring for other babies.
During Baby H’s time at the Countess, she had a recurring pneumothorax and three chest drain procedures. She was also placed on ventilation. The jury delivered a not guilty verdict in relation to the count of attempted murder in relation to the first collapse. The jury could not reach a verdict in relation to the second collapse. After the collapses, Baby H was transferred to Arrowe Park Hospital on 27 September 2015.
On 24 September 2015, Mother H was in a wheelchair and had been waiting for Father H to take her downstairs. Father H took Mother H down to the neonatal unit. She saw that Baby H had deteriorated since the previous evening and was now on ventilation. Mother H informed the Inquiry that no one had informed her or anyone else in the family about Baby H’s decline. She stated:
“I asked the doctor what was going on and I was told that she had been put on a ventilator. I really couldn’t understand why I’d not been informed of this earlier because we were told that she was okay. You know, I’d always check and would always ask how she was, and we were told that she was okay, you know, that she was okay. I was only upstairs. I knew they were busy but if it was something that significant to me, a ventilator sounds like a really scary and a really big change and there was no indication that that was going to happen that we were told of.”¹²²

Mother H recalled asking: “[W]hat had happened? Why did she all of a sudden … obviously she had deteriorated and I don’t remember anyone giving me a clear explanation as to why she had deteriorated.”¹²³

Mother H made a complaint to the Patient Advice and Liaison Service (PALS) about why no explanation was forthcoming about Baby H’s deterioration. Later that day, Dr Gibbs apologised and stated there would be more timely communication in the future.¹²⁴ Ms Powell’s reaction to the complaint was to criticise Mother H and express empathy for a nurse involved in the events. In an email response to the PALS complaint, Ms Powell wrote:
“My question as an addendum is why had it taken mum so long to come to the unit when she was aware how poorly her baby is. (just a thought) especially as she is an inpatient or even ask the midwife to ring/use her mobile for an update. I have spoken to Belinda and Nurse W as you can imagine Nurse W is upset that she has tried her best – only to receive this complaint.”¹²⁵
In oral evidence, Ms Powell confirmed she had made that remark without first speaking to Mother H and that she did not know that Mother H was having difficulty getting the midwives to take her down to the neonatal unit.¹²⁶ She also agreed that a mother finding her child ventilated was a scary experience and that “I’m sorry” was the appropriate response.¹²⁷ Ms Powell’s loyalty was first to the nurse. It led her to unjustified criticism of a mother who had proper cause for complaint.
Mother H was invited to comment on Ms Powell’s email. She described feeling “very, very upset”, and said:
“I am shocked that that is even part of a conversation between the nurse and the doctor, because she hasn’t got the full story there at all. And, you know, I am deeply offended by that. You know, like how dare she make a comment on that at such a difficult time? Because in actual fact I was an inpatient on the ward, I had asked many a times for the people up there to phone, to phone down. I had used my mobile to ring to check that she was okay, and I was told that she was stable, and I was trying my best to get down there. I wasn’t allowed to just go down on my own, so I couldn’t get down there easily. And I wasn’t aware of how poorly she was because I wasn’t told how poorly she was.”¹²⁸
Dr Jayaram was called into the hospital in the early hours of the morning of 25 September 2015 because Baby H had increasing ventilator requirements. Dr Jayaram stated: “[A]s I walked in it struck me it’s — it’s Letby. And my thinking at the time is, you know, she’s very unlucky that she seems to be associated with all of these.”¹²⁹
Dr Jayaram found the valve on Baby H’s chest drain was in a closed position and reopened it. At the time, he thought this may have happened accidentally, as a result of many hands being in the incubator during Baby H’s procedures.¹³⁰ He did not think anything untoward was happening at the time. He said: “I had noticed that association with Letby being present but not with any, any thought of anything untoward.”¹³¹ However, he stated: “[I] mentioned to Dr Brearey the next morning that it was — it was — it was Lucy Letby again, simply because I was thinking, well, she’s — she’s very unlucky.”¹³²
Dr Brearey could not recall Dr Jayaram mentioning Letby, but he did remember him raising questions about Baby H. He said it was not until 2016 or 2017 that he became more aware of the unusual nature of Baby H’s care, when the consultants discussed unusual morbidity cases that had occurred in relation to Letby.¹³³ Eighteen months later, on 15 March 2017, Dr Jayaram disclosed the incident with Baby H’s chest drain to Ms Sue Hodkinson, Director of HR.¹³⁴
Dr Gibbs stated both he and Dr Jayaram had noticed that Letby had been caring for Baby H. Dr Gibbs said that, around that time, “we were trying to make sense of the number of collapses and deaths that were happening and then realising that Letby was around for many”.¹³⁵
Baby H had a further collapse in the early hours of 26 September 2015 and she was resuscitated. Mother H described Baby H as “very, very pale”, with “sort of blue-purple marks, like a mottling, all over her body”. She said: “[W]e didn’t know, I suppose, that that was anything different, because we’d never seen anybody being resuscitated on the brink, you know, of death, really, before. And it is something, though, that stuck in our minds.”¹³⁶
Mother H said: “I remember speaking with Dr Gibbs as to why it had happened, and we asked why she needed to be resuscitated, because, you know, that’s a major thing. And I just remember him saying to us he didn’t know. And, you know, why weren’t we told that this could potentially happen? And he said he didn’t know, and they didn’t anticipate it to happen.”¹³⁷
Dr Matthew Neame was a paediatric registrar at the Countess in September 2015. He cared for Baby H. He told the Inquiry that, prior to, or at the very beginning, of his placement at the Countess in September 2015, he had a “sense of being aware that episodes may have happened” in relation to babies who had unexpectedly died or unexpectedly required an escalation of care.¹³⁸ He had a vague recollection of being informed of this by another registrar who had been working at the Countess prior to him starting there. He was not aware of any specific information related to these episodes. Dr Neame did not recall any speculation of deliberate harm when he had started at the Countess in September 2015. He had thought the episodes were down to “bad luck” or a “bad run”.¹³⁹
In his written evidence to the Inquiry, Dr Neame described Baby H as having “challenging and unexpected episodes of deterioration”.¹⁴⁰ In oral evidence, Dr Neame said he had considered that Baby H’s second collapse “needed some further assessment and further investigations in order to try to identify the cause”.¹⁴¹
Baby H required adrenaline to be administered in the resuscitation that followed her collapse on 27 September 2015. Dr Neame stated it was “relatively unusual” to be required to use adrenaline when resuscitating a neonate.¹⁴² He gave evidence that he had not associated the unexpected collapse of Baby H with what he had heard about the unexpected collapses prior to arriving at the Countess. Dr Neame could not recall attending a debrief into Baby H’s collapses.¹⁴³
Dr Saladi was involved in Baby H’s resuscitation on 27 September 2015. In his written evidence to the Inquiry, he stated: “[I]t was not clear why Child H had deteriorated hence why I sought help from the tertiary unit as documented in the notes. Any unexplained deterioration in a child is worrying.”¹⁴⁴ In evidence, Dr Saladi said he had not linked Baby H’s unexpected collapse to Baby B’s collapse. He acknowledged that the consultants did not link the events.¹⁴⁵
Baby H was transferred to Arrowe Park Hospital later on the morning of 27 September 2015. Mother H told the Inquiry that Letby had given her a memory box of sorts for Baby H. She described it as “a red box, and it had a teddy bear on the top and inside the box was a cot card and her wristband from the Countess of Chester”. She said: “[T]here was also in a plastic bag with a white sticky label on the front that said, ‘For my Mummy and Daddy, xxx’ and it had her CPAP hat in it, the CPAP hat and things. To me it almost seemed a bit like a memory box.”¹⁴⁶ Mother H recalled: “I remember thinking that it was quite morbid. You know, because she was not dead … I remember not feeling entirely comfortable about that.”¹⁴⁷
Mother H described the impact of the events at the Countess as “overwhelming”. She said: “What happened has affected every aspect of our lives … it really isn’t easy to put into words to truly convey the enormity of it … It’s affected my trust in hospitals and the health service very, very deeply … I really do find it very traumatic to have to go back to a hospital.”¹⁴⁸

Further deaths on the unit

There were two further deaths in September 2015, neither of which led to charges against Letby. On 28 September 2015, Dr Gibbs sent Dr Mittal an email which stated: “We’ve had another neonatal death.”¹⁴⁹ Dr Gibbs said he had sent Dr Mittal the email as part of the CDOP process.¹⁵⁰ It is not apparent that Dr Mittal did anything about this information.
Dr Lambie told the Inquiry that in September 2015 staff were “starting to think the unthinkable”.¹⁵¹ When asked to define what she meant by the phrase, Dr Lambie explained “that there might be a person who’s deliberately causing harm”.¹⁵²
Dr Lambie described that at handovers “it was a regular topic of conversation” and that, on more than one occasion, she had a “heartsink feeling of oh, gosh, what’s going to happen today”.¹⁵³
She recalled seeing, at some point in September 2015, a “huddle of nurses in the corner over the computer and I asked what they were doing and one of the nurses replied that they were going through the rota just to make sure that there wasn’t somebody that was on for each one [of the deaths]”.¹⁵⁴ None of the nurses who gave oral evidence to the Inquiry recollected this huddle taking place. I am satisfied that it took place.
Ms Marshall told the Inquiry: “Lucy was the one common factor who had been on shift.”¹⁵⁵ She added: “[I]t was my impression that she was always in — yes she was always involved with what was going on when there was a major collapse.”¹⁵⁶
Dr Lambie gave evidence that she was so concerned by the increase in the number of deaths and collapses, and the unusual nature of them, that she discussed it with a medical colleague external to the Countess. She stated that they discussed the “hypothetical possibility that, yes, at some point we might be needing to get the police involved”.¹⁵⁷
Dr Davis said:
“During my 6-month rotation in COCH [the Countess] in 2015 it became clear that we were experiencing an above average rate of death and collapses. As a group of trainees, we discussed if we felt we were missing something. Due to the small number of middle grades and close working of the team it was, and still is, common practice to debrief informally with colleagues following a stressful event. As a result, we all knew that other babies had collapsed unexpectedly and in atypical ways. When we attended regional teaching or local paediatric courses, colleagues would ask if we were doing okay, as they had heard that we were having a particularly bad run in CoCH.”¹⁵⁸
Ms Kathryn Percival-Calderbank was a senior neonatal practitioner (band 6). She was not aware of, and was not involved in, the huddle of nurses that Dr Lambie observed checking the rota to see which staff were on shift for the deaths. However, she recalled that it was common to ask who was on shift for the deaths. When she was told that Letby was present, she can remember saying to a colleague, “If somebody’s not careful, they’re going to think there’s something untoward happening here.” She said that she began to “start worrying”. She thought: “[W]hat are we missing? What’s — what are we not seeing here?”¹⁵⁹
The phrase ‘what are we missing?’ was used over and over again in this Inquiry, as nurses, doctors, managers gave evidence about their discussions at the time. It is a reasonable question when unexplained deaths are occurring. By the latter part of 2015, people were beginning to ask themselves whether there was a link between Letby and the deaths. They were not missing that – it was in front of them. What was much more difficult was to acknowledge what that might mean.
Ms Percival-Calderbank explained she had been working on the neonatal unit for ten years in 2015. She said: “[I]n the period of the time before this – these – these four deaths [Baby A, Baby C, Baby D and Baby E] I’d never known to have that many deaths in such a short period of time … I’d not dealt with as many deaths before that.”¹⁶⁰

Ms Powell’s instruction to shift leaders about Letby

A time came when Ms Powell had given the instruction to shift leaders that Letby was not to be scheduled to look after intensive care babies. When Ms Percival-Calderbank implemented those instructions, she met serious resistance from Letby. Ms Percival-Calderbank said:
“I think it must have been probably in the early stages [… Ms Powell] asked me to try and not let nurse Letby work in intensive care for her … mental health and well being after dealing with a death. So … she’d asked me as shift leader not to put her into the intensive care nursery, to put her into the outside nurseries for her … own mental health and well being which I had … put down … for the shift. … Lucy Letby then shouted at me for doing so because she felt she didn’t want to be in [an] outside nursery she wanted to be in the intensive care setting because she felt that it was boring looking after the special care babies.”¹⁶¹
Ms Percival-Calderbank said she had found Letby in intensive care several times during a shift when she had been allocated to an outside nursery. She had reported this to Ms Powell, who said: “[W]e’ll just have to try and stop her — stop it again when you can.”¹⁶² This was an inadequate response, repeating the failure to deal with Letby’s conduct with Baby C.
Ms Powell agreed that Letby really wanted to be in intensive care, and she had discussed this with other nurses, including Ms Percival-Calderbank.¹⁶³ She did not speak to Letby about this. There are two possible explanations for that: either she did not think this conduct was serious, or she did not want to confront Letby. The first is out of the question, since the instructions to put Letby on an outside nursery had come from her. The second is possible, since Letby was prepared to take on extra shifts, so it may have been that Ms Powell did not want to upset her. Whatever her reasons, Ms Powell was allowing Letby to break the rules. Letby was not a senior nurse – she had only been qualified for three years. Ms Powell had a duty to manage her effectively. She failed to do so over the morphine incident (see Chapter 2). She failed to do so when she interfered with the care of Baby C (see Chapter 3). She failed to do so here. As a result, Letby knew she could ignore instructions from a shift leader, she could shout and she could move between nurseries to find excitement. There were no adverse consequences for her arising from any of those behaviours. This was a management failure by Ms Powell.

Endnotes

Chapter 4

Risk and Patient Safety Department

Chapter 6

August 2015 to February 2016: Baby I and Baby J; concerns increase; reviews

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