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The Report
Volume II
Part One (continued)
Chapter 17

Chapter 17. July 2016: Redeployment of and support for Letby

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Chapter 16
Meetings on 13 and 14 July 2016
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Chapter 18
Nursing and Midwifery Council

Contents

Letby’s redeployment

  1. As set out in the previous chapter, Ms Powell and Ms Sian Williams had met Letby on 14 July 2016 and explained that she had been identified as being “more regularly involved in the care” of those babies who had collapsed and deteriorated on the neonatal unit. She and all those staff who had regular involvement in the care of the babies concerned were to be provided with a period of supervised practice.1 The period of supervised practice was due to commence on 18 July 2016, until which date it was agreed that Letby would go on authorised leave. This would continue pending the completion of an external review by the RCPCH.2
  2. Ms Sian Williams told the Inquiry she felt like she was the messenger between Letby, Ms Hodkinson and Ms Kelly. She thought that the Trust should have been more transparent with Letby and that “with the benefit of hindsight, I should have stood up a bit more to her [Ms Hodkinson]”.3
  3. Ms Hodkinson agreed that the hospital was not transparent with Letby and that this was a subsequent finding in the grievance.4
  4. On 15 July 2016, Ms Sian Williams approved an email drafted by Ms Powell and Ms Griffiths which was sent to all nurses on the neonatal unit:
    “In preparation for the external review it has been decided that all members of staff need to undertake a period of clinical supervision … we have decided that it would be useful to commence with staff who have been involved in many of the acute events … Therefore Lucy has agreed to undergo this supervision first.”5
  5. Ms Hodkinson admitted that it was only ever Letby who was going to undergo supervision.6 Ms Sian Williams was unaware of this. She thought that all the nurses on the unit were to undergo supervision. She acknowledged that, in failing to mention the concerns about the increased mortality and harm to babies, the email misled the nurses on the neonatal unit and they remained in the dark as to what was going on.7 Ms Sian Williams – the Deputy Director of Nursing – was misled. All the nurses on the unit were misled as to the reason for supervision. This was bound to and did lead to nurses feeling one of their number was being singled out for unfair treatment.
  6. A meeting was held on 18 July 2016 which included Letby, Ms Rees, Ms Griffiths, Ms Farmer and Mr Tony Millea (RCN). Ms Rees sent a letter to Letby summarising the meeting. The letter set out that it was not possible to provide her with full-time supervised practice because of staffing levels on the neonatal unit. As a result, a decision had been taken to redeploy Letby to the Risk and Patient Safety Department instead, where she would be line-managed by Ms Millward.8
  7. The letter referred to the redeployment as “temporary” and a “neutral act … taken in the best interest of all parties and in the interests of patient care, pending completion of the external review”. Letby was told that she could maintain social contact with her colleagues on the neonatal unit but that she “should be mindful of discussing any matters which may be sensitive in nature, relating to the [RCPCH] review of the NNU [neonatal unit]”.9 Letby was later to say to the RCPCH and others that she had been told not to contact her colleagues on the neonatal unit. This was not true.
  8. Although Ms Rees informed Letby about the redeployment, it was not her decision that Letby should be redeployed. She told the Inquiry that she returned from annual leave shortly before 18 July 2016 and was told that management had decided to remove Letby from the unit.10 Like Ms Sian Williams and Ms Hodkinson, Ms Rees considered that the hospital was not transparent with Letby about what was actually going on.11 They were all right about that.
  9. In oral evidence, Ms Millward informed the Inquiry that it was her idea for Letby to be redeployed to the Risk and Patient Safety Department. She explained that the management of Letby was discussed in an Executive Team meeting she attended. She perceived that the executives were looking for, and struggling to find, answers because the consultants had made clear that they did not want Letby to work on the unit when she returned from annual leave. Ms Millward stated: “I am absolutely confident that Mrs Hodkinson said something along the lines of ‘there’s not enough’, meaning not enough evidence ‘there is not enough to exclude her, suspend her’.”12
  10. Ms Millward explained her rationale for suggesting Letby be redeployed to the Risk and Patient Safety Department: “I felt I wanted to help … I also felt that, you know, given the fact that somebody was being moved with — with no real explanation I felt that she did warrant to have some support in place.”13
  11. Ms Millward’s understanding was that Letby’s redeployment would be a temporary move while the RCPCH review was carried out (which she thought would be completed within eight weeks). She stated that Letby joined the complaints team and was based in an office with administrative staff.14 She reflected that, in hindsight, it was not appropriate for Letby to join her team and that, once the RCPCH report was complete and Letby’s grievance had commenced, “[A]t that point I really should have said ‘I think we need to move her now’ because there was no end in sight at that point.”15
  12. On reflection, Ms Sian Williams considered the redeployment to the Risk and Patient Safety Department “was probably not appropriate”.16 At the time, she raised a concern that Letby may have had access to material about babies on the neonatal unit via the computer system.17

Lack of transparency with legal advisers (DAC Beachcroft)

  1. In July 2016, the hospital obtained legal advice from Mr Ian Pace and Ms Corinne Slingo at DAC Beachcroft (Associate, Employment and Pensions, and Head of Healthcare Regulatory, respectively). The advice concerned two issues: Letby’s redeployment; and whether the police should be called. Ms Hodkinson confirmed that it was her decision to obtain legal advice regarding matters related to Letby.18
  2. Ms Appleton-Cairns told the Inquiry that, on 5 July 2016, she contacted Mr Pace because there was consideration of removing Letby from her role, but the evidence and grounds against her were quite vague. She explained:
    “I was just checking if we were to remove Lucy Letby from the unit, then what would be our risk from another direction, which is the direction of Lucy Letby who was being heavily backed by the RCN and what that risk would be if we were to move her … what we came to in the end was that obviously the — that risk was not as big as the risk that she may be harming babies and in which case we had to move her.”19
  3. Ms Appleton-Cairns was taken through key sections of the file note that documented her call with Mr Pace.20 She confirmed that she made reference to Beverly Allitt and that, in 2015 to 2016, she was aware of that case.21 She was asked about the passage in the file note that read: “Dee is satisfied that there are no malicious issues involved.” She explained that she was satisfied of this because Mr Harvey and Ms Kelly had given her “assurances” that there was nothing malicious.22 Whatever assurances she may have received, she knew the doctors were concerned that Letby was harming babies. It was not for her to declare herself satisfied that there were no malicious issues involved. Her approach suggests that she gave no credence to the concerns, not least because she had not troubled to learn the details.
  4. Ms Appleton-Cairns denied that she was minimising the problem in her call to Mr Pace. When asked in evidence about “a large number of unexplained, unexpected deaths on the neonatal unit”, she responded: “At that point … it wasn’t that many.”23 This was a most unfortunate observation. There had been 13 deaths in little over a year. She informed the Inquiry that she was not aware there had been 13 neonatal deaths on the neonatal unit between June 2015 and June 2016 and she had not seen the Thematic Review when she called Mr Pace.24 If this is true, and I see no reason why it would not be, it shows at best a lack of application to her role and no appreciation of the seriousness of the situation. It is likely that she gave no credence to the doctors’ concerns. She asserted in evidence that there was “no commonality on the — on the spreadsheets”.25 This was not true. She said: “The only Consultant that I knew of that was expressing any kind of concern for a long, long time was Dr Brearey.” Again, this was not true. She went on: “So for me there was — there was nothing here other than Dr Brearey saying he had some concerns about a nurse, a specific nurse.”26
  5. Mr Pace said in evidence that he received a call from Ms Appleton-Cairns seeking advice on the breakdown of working relationships and concerns about an individual member of staff’s involvement in neonatal deaths. In the call, she told him that a consultant had referred to the individual as ‘Beverly Allitt’. Mr Pace regarded this as a “red flag”.27 He was right to do so. So should every other person involved.
  6. Mr Pace perceived that Ms Appleton-Cairns lacked “recognition, perhaps, of the issue”.28 He stated: “I wanted to effectively switch the focus from effectively what was a relatively minor issue of breakdown in working relationships to clearly a very serious — potentially very serious matter.”29 The file note reflects that he advised Ms Appleton-Cairns that the employment considerations paled into insignificance.30 He was right to do so. It is dispiriting that Ms Appleton-Cairns needed that to be explained to her. It reinforces my view that she gave no credence to the concerns.
  7. The file note also records that Mr Pace advised Ms Appleton-Cairns that there was a potential risk of a constructive unfair dismissal claim if she resigned. He advised that the Trust should put in place steps to justify a satisfied position that there was a suggestion or evidence to link the individual to the deaths so that the Trust would have a defence if it decided to suspend Letby.31 Mr Pace emphasised that he was acting in his capacity as an employment solicitor and that the advice about suspension was in line with Acas guidance.32
  8. Mr Pace explained he did not suggest an immediate suspension or that a safeguarding referral should be made because Ms Appleton-Cairns provided him with limited information and presented “a confusing picture”.33 Thus, he thought it was best to obtain specialist regulatory advice before suggesting those steps.
  9. Following the call, Mr Pace spoke to Ms Kirsty MacDonald, Head of Employment at DAC Beachcroft, who advised him to speak to Ms Slingo. Mr Pace thought that he told Ms Slingo everything Ms Appleton-Cairns told him.34
  10. At some point between 5 July and 18 July 2016, Ms Slingo read Mr Pace’s note of his call with Ms Appleton-Cairns from 5 July 2016.35 She noted that a consultant had made reference to Beverly Allitt. She commented: “[F]or any healthcare lawyer at that time, one would regard a reference to [Beverly] Allitt as suggesting that there was a deliberate harm element to the patient safety concern.”36 However, she emphasised that the file note also recorded that Ms Appleton-Cairns was satisfied that there were no malicious issues.37 Both Ms Slingo and Mr Pace accepted what Ms Appleton-Cairns said at face value. I repeat, it is not easy to see how a doctor referring to Beverly Allitt was consistent with an absence of malicious issues.
  11. At 17:00 on 18 July 2016, Ms Slingo spoke to Ms Hodkinson. This was the first time she had spoken to someone at the Trust. Her evidence was that the call lasted 42 minutes and that at 18:15 she sent Ms Hodkinson and Mr Pace an email outlining her advice.38 In Ms Slingo’s email she sets out her understanding of the consultants’ concerns and the context to her advice:
    “Based on the fact that:
    • the only current evidence of any clinical concern is the (potentially circumstantial) fact that one particular nurse was on shift on more occasions than others at the point when neonatal deaths arose, and
    • there are also deaths/deteriorations that occurred when she was not on shift, and
    • No incidents have been linked to her practice, and
    • No previous concerns or whistleblowing has arisen in respect of the individual or the unit, and
    • There is currently no cause of death or thematic clinical basis to suggest the deaths are connected to each other, or connected by a common intervention (deliberate or not), and
    • Approximately 75% of the deaths have also been through the coronial system, with no common feature or issue arising from the individual’s care.”39
  12. Ms Slingo was asked whether she felt misled by the incomplete information that was provided to her in the calls with Ms Hodkinson. She responded: “I do think that I didn’t have all the information that you suggest was available by the July period in 2016, because it doesn’t feature in my note as part of the narrative and the history given by Sue … if I wasn’t told everything that was known, then that would be disappointing to find out and that appears to be the case.”40
  13. Ms Slingo confirmed that she was not aware that the majority of the deaths had occurred between midnight and 4am when Letby was on night shift, or that they stopped at night when Letby was moved to days and then occurred during the day, nor was she aware that the doctors were concerned that the deaths were unexpected and unexplained. She said that she did not know the consultants were concerned that Letby was deliberately harming babies.41 It is not clear how that fits with the earlier reference by one of the doctors to Beverly Allitt but Ms Slingo did not ask about this. She explained: “[T]he entire tone of this call wasn’t that there is a deliberate harm situation.”42 She added: “I did not take away from that call the idea of there is a nurse potentially killing babies.”43
  14. Ms Slingo explained that what she understood from the call was that the Trust had experienced some anomalies with mortality data and there was a concern about an individual’s involvement with the deaths, which they were trying to understand.44 The impact of Ms Slingo being provided with incomplete information is borne out in her advice:
    “There does not currently appear to be any reason to formally alert the police to these issues, as there is nothing upon which one might reasonably base a suspicion of a criminal offence having been committed. We advised that this fine balance of decision making be kept under very close review, with a very low threshold for moving this to a decision to notify the police, in the event any clinical evidence comes to light in the ongoing investigations that tips the balance in favour of alerting them.”45
  15. Ms Slingo’s evidence was that, given what she now knows, she wished she had advised the Trust to contact the police; however, at the time deliberate harm was not at the forefront of her mind. She said, had there been any concern that there was deliberate harm or killing of babies, “there would be no question that my advice would have been very different”.46
  16. At the end of her email, Ms Slingo wrote that it would be helpful to see the Terms of Reference for the RCPCH report; however, neither the Terms of Reference nor the report were ever provided to her.47
  17. Ms Hodkinson confirmed in evidence that she did not send Ms Slingo the Thematic Review.48 She was not sure whether she had mentioned that the Thematic Review noted a pattern of deaths in the night-time and Letby’s presence on those shifts.49 She initially stated that she could not recall whether she had mentioned that the consultants had concerns about an Allitt/Shipman type situation. She then appeared to admit that she did not say this, when she reflected “potentially maybe I should have done but I — it wasn’t around a misleading point or any aspect there”.50 If she did not mention it, she should have done.
  18. Ms Hodkinson was invited to comment on Ms Slingo’s evidence. She was not particularly reflective, telling the Inquiry: “[Ms Slingo] should have asked me more questions … I felt that I was giving a clear and honest and truthful overview at that time.”51 Her account was partial. I find that she did not tell Ms Slingo about the pattern of deaths and the doctors’ concerns that babies were being deliberately harmed. She should have done so. No more than that needed to be said to cause a radical change in the legal advice being given. Ms Hodkinson did not give Ms Slingo crucial information about the doctors’ concerns.

Support for Letby

  1. On 30 June 2016, after the deaths of Baby O and Baby P, Ms Powell referred Letby to the Occupational Health Department for support.52
  2. Ms Kathryn De Beger was the Occupational Health Manager. She qualified as a nurse in 1985 and began working as an occupational health nurse in 1995. In 2009, she joined the Countess in that role and became the Occupational Health Manager in 2010.53 She was line-managed by the Director of HR, Ms Hodkinson, but Ms De Beger and her team were independent of the HR department. She explained that the team was there “to support and give advice to members of staff going through those policies [HR policies, management policies] in a very independent, impartial manner and non-judgmental [way]”.54
  3. In her referral, Ms Powell wrote: “As I mentioned … on the phone … I have requested that Lucy come to the occupational health department for support especially in view of the proposed allegation that will evidently come to light.”55 Ms De Beger said that when she received the written referral she was unaware of the nature of the allegation.56 She was aware of an increase in deaths on the neonatal unit and that there was an investigation. She also knew that Letby had been redeployed to a non-clinical role at about the same time the investigation was announced and had made the connection that Letby may be involved in some way. However, she was not aware that she was accused of deliberately harming patients.57 The role given to her by the Trust was “to support her, to support her mental health, to support her well-being” and “to support her through this investigation”.* 58
  4. Ms De Beger met Letby for the first time in mid-July 2016, when Ms Powell accompanied Letby to the Occupational Health Department.59 She learnt of the nature of the allegations at some point during her meetings with Letby.60 In addition to formal weekly meetings with her, she also had very frequent email and, later, text message contact with Letby. She kept in touch with Letby even when she (Ms De Beger) was on holiday. During a 15-month period between March 2017 and July 2018 (when Letby was arrested), they exchanged over 400 WhatsApp messages. It was clear from her evidence that she discharged her responsibilities with great care and was an excellent support to Letby. Contrary to some reporting, Ms De Beger was not a counsellor and there is no evidence that counselling or any form of therapy was provided to Letby.
  5. In addition to the support from Occupational Health, Letby also had weekly or fortnightly meetings with Ms Hodkinson, Ms Kelly and Ms Rees. This was a very senior team, which supported Letby throughout (with Ms Rees as mentor).61 They made it plain to her that the expectation was that she would be returning to the neonatal unit. They provided her with updates of all the management meetings that concerned her and they ensured she had a copy of the RCPCH report before the consultants did.62
  6. As of April 2017, a WhatsApp group was set up which included Letby, Ms De Beger, Ms Cooper and Ms Rees. There were over 750 messages in that group between April 2017 and July 2018, in addition to those between Ms De Beger and Letby only. Ms De Beger said that she had never – before or since – been in WhatsApp contact with a person she was supporting.63 She explained that she took this different approach because Letby was in a distressing situation and because, as she stated: “I felt that at that time I was the only support that Lucy Letby had.”64
  7. During her evidence, Ms De Beger was referred to a passage in her police witness statement, which read: “Lucy did ask for meetings with me on anniversaries of some of the babies’ deaths as she was particularly distressed.”65 In evidence to the Inquiry, Ms De Beger modified that and said it had happened only once. It was not something that any other nurse had asked for.66 The distress shown by Letby on the anniversary contrasts with her response to the deaths at the time they occurred.
  8. Ms De Beger was not alone in believing she was Letby’s only support, and she became very close to her. This echoed what was said by Ms Cooper and Dr U (see Chapter 11). Further support came from Dr U. He was an experienced registrar. He worked at the Countess from September 2015 to September 2016 as the most senior of the junior doctors. He then worked as a locum consultant at Alder Hey.67 Dr U said in evidence that he began Facebook messaging with Letby in June 2016.68 Between June 2016 and September 2016, they exchanged approximately 1,355 messages.69 When asked to explain the reason for such frequent contact, he said: “Letby was struggling with her mental health and I think I picked up on that and I’d offered some support, and that support, it grew, and I understand that she slept very poorly because of worry and anxiety, and there were often messages that were passed throughout the day and sometimes late at night, earlier in the morning.”70 I have referred (see Chapter 11) to their messages at the time of the collapses and deaths of some of the babies. I do not repeat them. Like Ms Cooper, Ms Rees and Ms De Beger, Dr U was content to be a close support of Letby.
  9. The effect of Letby’s displays of distress was that all those supporting her (Ms De Beger, Ms Cooper and Ms Rees) were genuinely sympathetic towards her and gave her a great deal of attention and support. The intensity of the situation brought all the people in the WhatsApp group together. Whilst Ms Cooper and Ms De Beger were responsible for supporting Letby, Ms Rees’s position was different. She was the Divisional Head of Nursing. She should have maintained appropriate distance. She accepted in evidence that she had become too close to Letby, as a result of the frequent contact: “[Y]es, because I was tasked to meet with her on a near weekly basis for nearly two years.”71 In evidence, Ms Rees said that she was given a management instruction from Ms Kelly and Ms Hodkinson “to meet with her [Letby] on a weekly basis with my two other senior colleagues to support her health and well-being during all of this and to give her feedback from any investigations”.72 It is likely that this made it impossible for her to be objective about the issues that had been raised by the doctors. Ms Kelly’s participation in the meetings was ill judged. As a senior manager, she should not have been involved in supporting Letby. She acknowledged that her involvement in supporting Letby and direct conversations with her were inappropriate.73
  10. Letby also had the support of both her parents, although Ms De Beger recalled that there was a difference of opinion between Letby and her father about how to proceed.74 Mr Letby said that the police should be called, a view he also expressed in meetings with the executives (see Chapter 23). Letby did not want this. Ms De Beger denied that Letby’s father had ever telephoned her or harassed her, as had been asserted by another witness to the Inquiry.75
  11. There were good reasons to support Letby, and the hospital was right to do so, but every person who supported her stepped very quickly from professional support to personal friendship. They were all relatively senior people. They should have maintained an appropriate professional distance and not become involved.
  12. On 23 June 2016 at 09:55, Letby messaged Dr U saying: “I lost my handover sheet. Found it in the donor milk freezer. Clearly I should still be in Ibiza.” Ms Powell was asked about the contents of this message in oral evidence. She said she did not know how it had happened. She also did not know that Letby had taken 241 handover sheets home in 2015 to 2016. Ms Powell confirmed that handover sheets should not leave the unit and she was very surprised to learn that Letby had taken handover sheets off the unit.76
  13. Letby kept 241 handover sheets stored at her home. Twenty-one of those sheets related to babies named on the indictment.77 There is no evidence that any nurse, doctor or manager was aware of Letby doing this at the time, nor could anyone explain this practice. Whilst I can understand that sometimes a nurse or doctor may (whatever the rules may be) take home a handover sheet to complete their notes, and it may well be that sometimes this is done absent-mindedly, the taking and retaining of such large numbers of handover sheets is deliberate and worrying behaviour and obviously contrary to good nursing practice.
  14. A handover sheet for Baby H was found in a plastic bag under Letby’s bed at her home after her arrest. Handover sheets for Baby G and Baby I were also found. She took and retained information about Baby E and Baby F. Mother E and F’s evidence was that she learnt at the criminal trial that Letby “had Child E’s and Child F’s sensitive data stored at her home and she actually moved house and actually took it with her in a Morrison’s carrier bag”.78

Visits to Alder Hey

  1. In addition to support by text message and while working with Letby, Dr U later helped her to secure theatre observations at Alder Hey in Liverpool, where he was working as a locum consultant. Dr U wrote the following email to colleagues:
    “Dear colleagues …
    Lucy Letby is a band 5 staff nurse [from the Countess] with an interest in NICU [neonatal intensive care unit] nursing of post-operative babies. In order to facilitate her personal development, she would like to have the opportunity to observe some theatre sessions. Mr Lamont feels that there is no problem from a surgical perspective.”79
  2. In evidence, Dr U said he had assumed that, if Letby’s visits to Alder Hey were not appropriate, HR or the nursing management team would have said ‘no’.80 However, he conceded that he did not actually have confirmation that this had been formally approved by the Countess: “I, again in hindsight, was remiss not to complete the loop and check that that was correct. But my assumption here was that in offering a letter of access, with contact with the Countess of Chester, that had all been signed off as appropriate.”81
  3. In a meeting on 31 January 2017, between Letby, Ms Kelly, Ms Rees, Ms Cooper and Ms Hodkinson, the meeting summary notes: “[Y]ou [Letby] advised how you have been liaising with a colleague based at Alder Hey to view theatres lists and to have observational contact. We agreed that you would work with Karen to come back with a plan around this within the next week.”82 Ms Rees was referred to this note in oral evidence and was asked about her knowledge of the Alder Hey visits. Her response is set out below:
    “If I recall, Lucy Letby had a friend, a medical colleague that worked — she had obviously worked with him prior and he was currently based at Alder Hey Hospital and I recall her arranging to have this observational contract with this particular medic, so she could sit in his clinic and just observe. There was no hands-on clinical contact as far as I was aware, made aware. But I do recall once that had been — Lucy had set that up with this particular medic, that Alison Kelly then on hindsight retracted it and stopped it.”83
  4. Ms Rees confirmed that she did not contact Alder Hey at any time to either confirm or prevent that placement and did not get involved in this arrangement.84
  5. Dr U accepted that he did not inform Alder Hey that Letby was not looking after babies on the neonatal unit.85 He informed the Inquiry that “she was still having patient contact at that time … in the clinic rooms”, as part of her non-clinical role conducting clinical audits in the Obstetric and Gynaecology Outpatient Department.86 This was not something mentioned by any of the managers but I see no reason why Dr U would have invented it. He said that he understood that Letby was later moved to an administrative role, while she retrained. This was a reference to her redeployment to the Risk and Patient Safety Department.
  6. Dr U succeeded in organising the observations at Alder Hey. The details appear in a feedback form he prepared for Letby’s application to the Nursing and Midwifery Council (NMC) for revalidation (see Chapter 18). He said that he had worked with Letby between September 2015 and September 2016 on the neonatal unit at the Countess. As with Alder Hey, he did not mention to the NMC that Letby had not worked on the neonatal unit after the end of June 2016. His summary of Letby’s observations at Alder Hey between December 2016 and August 2017 read:
    “22/04/2017
    Attendance at Insulin Pump roadshow
    Lucy attended the Alder Hey Insulin pump road show along with [patients] and the [families] to be educated on the pros and cons of Insulin pump therapy and the relative benefits of the supported Insulin pumps used by our service.
    Lucy met with the various pump [manufacturers] and participated in demonstrations of subcutaneous cannula insertion.
    Lucy demonstrated a keen interest in acquiring new skills and knowledge and I hope she felt this road show was beneficial.
    18/08/2017(Dec 2016 – April 2017)
    Clinical observation at Alder Hey Children’s NHS Foundation Trust
    For a period of 4 months Lucy has been attending Alder Hey Children’s Hospital in order to experience the breadth of secondary and tertiary paediatric services provided.
    Lucy has observed General Paediatric outpatient and diabetes Clinics. She has observed renal dialysis and been taught about peritoneal dialysis, as well as sitting in on a complex discharge planning meeting.
    Lucy has spent a day observing nursing practice on the Paediatric Intensive care Unit.
    All of the teams that participated in offering the sessions to Lucy have commented on how keen she has been to acquire new skills and to gain knowledge experience outside of her normal working field.”87
  7. He added at the bottom of the form: “I have worked with Lucy between September 2015 and September 2016 on the CoCH [the Countess] Neonatal Unit.” In fact, the period finished in early July 2016. He then wrote: “We have worked together on babies with acute admissions, labour ward transfers and a range of gestations from 26-40 weeks.”88
  8. Dr U was writing this in late August 2017. By then, he knew that Letby had not looked after babies on the neonatal unit for over a year. He knew the police were investigating and that there were concerns about Letby. He did not mention that on his form. The form did not require it. Nor did he mention that she had been moved from the neonatal unit to a non-clinical role. Again, there was no requirement upon him to do so.
  9. At the end of his evidence, Dr U said: “I think I’ve become more aware that I wasn’t aware of the full clinical picture, and I provided support by being misled and maybe manipulated, and for that … I’m really sorry that things have come to end as they have. I have a lot of regrets about how that period of time took place.”89

Use of mobile phones

  1. Some parents were understandably distressed to hear of the text messages between Letby and other staff about them and their children.90 Concerns were expressed about the use of mobile phones by nurses and doctors to communicate about patients when they were not on the neonatal unit. Parents were shocked that they and their children were being discussed with no thought for their privacy. Mother E and F’s concerns extended to the distraction that mobile phones presented:
    “I think for me, they need the full concentration on the babies, and if phones are going to be used, have them in their break rooms. They shouldn’t be in their pockets. They shouldn’t be able to be accessed in non-clinical areas such as the nurses’ station … I think having a phone is a big distraction, and I think that they should be left in their lockers, and I think that should become common practice.”91
  2. Ms Powell’s evidence was that, in 2015 to 2016, whilst there were discussions about midwives using translation apps on mobile phones to overcome language barriers, she was clear that a nurse’s mobile phone “was not to be used for personal use”.92
  3. Doctors and nurses are not provided with mobile phones for use at work. They are expected to, and do, use their own devices for clinical and related calls and messaging. In many places mobile phones have replaced bleeps or pagers. In the ten years since the events I am describing, the use of mobile phones has become almost universal. The principal use is as a computer with many apps – search engines, medical and nursing websites, banking, shopping, livestreaming and so on. WhatsApp groups were used at the Countess and I have commented on some of them. I have no doubt that they (or some other encrypted messaging services) are still used between staff across the NHS. I agree with Mother E and F that there is a risk of a phone becoming a distraction, but it is my impression that for most doctors and nurses the phone is an essential connection to, for example, information about procedures/symptoms via search engines and medical websites, as well as to communicate appropriately about patients and other work-related matters. Like all other working people, nurses and doctors have to discipline themselves during long working hours not to be distracted by personal matters, on the phone or otherwise. I do not think it right to recommend removing mobile phones from doctors and nurses while at work.
  4. One of the dangers of WhatsApp or similar apps generally is the forwarding of messages from within a closed group to another person. At that point, control of the information is lost. That does not happen with a telephone call. If someone receives information and wants to pass it on, they have to make another call or send a message. That makes the unthinking passing on of the information less likely. The ease of communication via messaging apps leads, as email does, to a less cautious approach to communication.
  5. The NMC now has guidance on using social media responsibly, which covers issues such as sharing confidential information inappropriately or posting inappropriate comments about patients.93 The guidance emphasises that sharing confidential information online can have the potential to be more damaging than sharing it verbally, due to the speed at which it can be shared and the size of the potential audience. Similarly, the General Medical Council (GMC) has issued guidance, with effect from 30 January 2024, entitled Using Social Media as a Medical Professional.94 Social media is defined as including private messaging. The guidance makes clear that “when using social media of any kind, you must maintain patient confidentiality and recognise and respect patients’ dignity and their right to privacy”.95

Footnotes

  1. * This is in reference to the RCPCH report.

Endnotes

  1. 1 INQ0003147/2

  2. 2 INQ0003147/2

  3. 3 Sian Williams 5 November 2024 68/19-25

  4. 4 Sue Hodkinson 26 November 2024 86/3-6

  5. 5 INQ0002879/91

  6. 6 Sue Hodkinson 26 November 2024 86/13-18

  7. 7 Sian Williams 5 November 2024 55/17-25

  8. 8 INQ0002458

  9. 9 INQ0002458

  10. 10 Karen Rees 21 October 2024 154/2-15

  11. 11 Karen Rees 21 October 2024 153/23-25

  12. 12 Ruth Millward 4 November 2024 201/2-5

  13. 13 Ruth Millward 4 November 2024 201/20-25

  14. 14 Ruth Millward 4 November 2024 201/12-18

  15. 15 Ruth Millward 4 November 2024 202/7-9

  16. 16 Sian Williams 5 November 2024 58/19-20

  17. 17 Sian Williams 5 November 2024 59/6-15

  18. 18 Sue Hodkinson 26 November 2024 60/3-7

  19. 19 Dee Appleton-Cairns 5 November 2024 191/8 to 192/21

  20. 20 INQ0101934/1

  21. 21 Dee Appleton-Cairns 5 November 2024 195/1-3

  22. 22 Dee Appleton-Cairns 5 November 2024 195/24 to 196/8

  23. 23 Dee Appleton-Cairns 5 November 2024 196/14-18

  24. 24 Dee Appleton-Cairns 5 November 2024 202/9 to 204/1

  25. 25 Dee Appleton-Cairns 5 November 2024 196/22

  26. 26 Dee Appleton-Cairns 5 November 2024 196/17 to 198/16

  27. 27 Ian Pace 21 November 2024 70/13 to 75/1

  28. 28 Ian Pace 21 November 2024 76/1-2

  29. 29 Ian Pace 21 November 2024 73/25 to 74/4

  30. 30 INQ0101934/1

  31. 31 INQ0101934/1

  32. 32 Ian Pace 21 November 2024 77/20 to 78/9

  33. 33 Ian Pace 21 November 2024 77/14

  34. 34 Ian Pace 21 November 2024 80/22 to 81/14

  35. 35 INQ0101934/1

  36. 36 Corinne Slingo 21 November 2024 115/9-12

  37. 37 INQ0101934/1

  38. 38 Corinne Slingo 21 November 2024 126/21 to 127/3

  39. 39 INQ0003397/2-3

  40. 40 Corinne Slingo 21 November 2024 157/18 to 158/12

  41. 41 Corinne Slingo 21 November 2024 130/3 to 132/25

  42. 42 Corinne Slingo 21 November 2024 132/23-25

  43. 43 Corinne Slingo 21 November 2024 156/20-22

  44. 44 Corinne Slingo 21 November 2024 124/6-11

  45. 45 INQ0003397/2-3

  46. 46 Corinne Slingo 21 November 2024 136/17-18

  47. 47 INQ0003397/3; Corinne Slingo 21 November 2024 138/12-25

  48. 48 Sue Hodkinson 26 November 2024 61/4-9

  49. 49 Sue Hodkinson 26 November 2024 62/8-17

  50. 50 Sue Hodkinson 26 November 2024 64/15-17

  51. 51 Sue Hodkinson 26 November 2024 64/22-24

  52. 52 INQ0018046/1

  53. 53 Kathryn De Beger 9 October 2024 40/23 to 41/10

  54. 54 Kathryn De Beger 9 October 2024 41/23 to 42/4

  55. 55 INQ0018046/1; Kathryn De Beger 9 October 2024 43/5-15

  56. 56 Kathryn De Beger 9 October 2024 43/16 to 45/4

  57. 57 Kathryn De Beger 9 October 2024 46/12 to 47/12

  58. 58 Kathryn De Beger 9 October 2024 51/24 to 54/21

  59. 59 Kathryn De Beger 9 October 2024 44/6-19

  60. 60 Kathryn De Beger 9 October 2024 48/7-12

  61. 61 INQ0003611/4

  62. 62 INQ0003471/2

  63. 63 Kathryn De Beger 9 October 2024 50/21 to 51/23

  64. 64 Kathryn De Beger 9 October 2024 51/22-23

  65. 65 Kathryn De Beger 9 October 2024 57/1-8

  66. 66 Kathryn De Beger 9 October 2024 57/9-16

  67. 67 Dr U 7 October 2024 167/24 to 168/6

  68. 68 Dr U 7 October 2024 183/15-19

  69. 69 Dr U 7 October 2024 183/20-24

  70. 70 Dr U 7 October 2024 184/1-7

  71. 71 Karen Rees 21 October 2024 178/2-9

  72. 72 Karen Rees 21 October 2024 159/8-14

  73. 73 Alison Kelly 25 November 2024 197/13-22

  74. 74 Kathryn De Beger 9 October 2024 55/18-22

  75. 75 Kathryn De Beger 9 October 2024 56/12-22

  76. 76 Eirian Powell 17 October 2024 117/17 to 118/16

  77. 77 Court of Appeal (Criminal Division) Judgement [2024] EWCA Crim 748 8/27 to 9/31

  78. 78 Mother E and F 18 September 2024 49/18-21

  79. 79 Dr U 7 October 2024 215/2-12

  80. 80 Dr U 7 October 2024 219/3-16

  81. 81 Dr U 7 October 2024 219/10-16

  82. 82 INQ0003471/5

  83. 83 Karen Rees 21 October 2024 170/3-13

  84. 84 Karen Rees 21 October 2024 170/14-17

  85. 85 Dr U 7 October 2024 217/17-23

  86. 86 Dr U 7 October 2024 217/23 to 218/6

  87. 87 INQ0100851/2

  88. 88 INQ0100851/3

  89. 89 Dr U 7 October 2024 222/4-10

  90. 90 Mother E and F 18 September 2024 50/13-23; Mother D 17 September 2024 6/17-21

  91. 91 Mother E and F 18 September 2024 50/24 to 51/9

  92. 92 Eirian Powell 17 October 2024 35/12 to 36/4

  93. 93 NMC, Guidance on Using Social Media Responsibly, 2 July 2015 (https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/social-media-guidance-2016.pdf)

  94. 94 GMC, Using Social Media as a Medical Professional, 30 January 2024 (https://www.gmc-uk.org/cdn/documents/using-social-media-as-a-medical-professional-final-version_pdf-105395775.pdf)

  95. 95 GMC, Using Social Media as a Medical Professional, 30 January 2024, page 6, para 18 (https://www.gmc-uk.org/cdn/documents/using-social-media-as-a-medical-professional-final-version_pdf-105395775.pdf#page=6)

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Chapter 16
Meetings on 13 and 14 July 2016
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Chapter 18
Nursing and Midwifery Council