UK - Lucy Letby - Post-Conviction Statutory Inquiry

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11:38am
A neonatal mortality meeting was held on July 29, 2015.
Ms Langdale KC says: "as a mechanism to explore and record concerns about deaths on the unit or identify trends, the neonatal mortality meetings do not appear to have been effective.
"It also appears that discussions may have been hampered by the lack of prompt post-mortem results."

11:44am
Ms Langdale KC moves to the cases of Child E and Child F.
Child E's death was 'to be discussed in the quarterly neonatal mortality review'.
"In fact, it appears that this never happened."

Live: Thirlwall inquiry into Lucy Letby baby deaths case begins
 
11:48am
Dr David Harkness, in a statement to the inquiry, says he would initiate a Sudden Unexpected Death in Infancy and Childhood procedure, which would involve a post-mortem examination in the case of Child E, with the benefit of his increased experience and knowledge now.
No post-mortem examination was pursued for Child E to save the parents further distress.
The cause of death was recorded as prematurity and necrotising enterocolitis [known as NEC in the trial], and no recommendations were made.

11:52am
Lucy Letby had agreed at trial that Child F and Child L had been poisoned by insulin, but denied being the poisoner.
Child F's low insulin c-peptide to insulin ratio test was relayed to the Countess of Chester Hospital. It was established that no other baby on the Neonatal Unit had been prescribed insulin, making accidental administration unlikely.
A Countess doctor's statement to the inquiry said: "I felt that the most likely explanation for the results was some sort of inaccuracy with the test and I would have liked to repeat them, but Child F had no further periods of hypoglycaemia and was transferred back to his local unit.
"It is our usual practice to repeat neonatal bloods that do not fit with the expected clinical picture."
She did consider whether insulin could have been delivered deliberately: “but this seemed absurd and ridiculously unlikely so the tests being wrong seemed the only possible explanation.”
She added in her police statement that: “with hindsight I should have flagged up this unexpected result.”

11:53am
Dr Gibbs, in his statement to the inquiry, said: "I helped during the initial management of Child F’s low blood glucose, in August 2015, at which time infection was suspected. Low blood glucose is a common problem in babies in early life, more so in premature babies.
"Blood results in Child F indicated that the low blood glucose was likely to have been caused by the administration of synthetic insulin. These blood results were only available several days after being taken, by which time the low blood glucose had resolved.
"The results were not interpreted correctly at the time and so, highly regrettably, an indication that someone was deliberately harming patients was overlooked.
"Not being aware of these insulin results meant that Child F did not cause me to be suspicious of deliberate harm on the NNU.”
Dr Gibbs characterises it as “a collective failure” on the part of the paediatric team to have not recognised the significance of the insulin and c-peptide results in Child F in mid-August 2015.

11:54am
Medical Director Ian Harvey has said in his statement to the Inquiry: “This situation [the insulin result] was not reported to me at any time before my retirement. It should have been. I feel strongly that had this been reported to me, this would have alerted me to an urgent problem and significantly altered my perception of the events on the neonatal unit.”

11:55am
Ms Langdale KC says to Lady Thirlwall: "In light of what we know about the facts of this case, and indeed the facts of the [Beverley] Allitt case and others, where the deliberate administering of insulin has been used to cause harm, you may consider that this is an area that requires particularly careful consideration."

Live: Thirlwall inquiry into Lucy Letby baby deaths case begins
 
11:59am
Ms Langdale KC turns to the cases of Child G and Child H.
Letby was found guilty of attempting to murder Child G on two occasions, and found not guilty on a third.
The jury gave a not guilty verdict for Child H's first collapse, and were unable to give a verdict for the second.
The handover sheet for Child H was found in a plastic bag under Letby’s bed at her home after her arrest. Handover sheets for Child G and Child I were also found. Letby kept 231 handover sheets stored at her home. Of those, 21 of those sheets related to babies on the indictment.

12:04pm
Ms Langdale KC recalls the events of Child I. Letby was convicted of his [my note, should be her, not his] murder.
Dr Gibbs could not understand why Child I had died. He contacted the coroner’s office as he was unable to provide a cause of death and he arranged for a debrief meeting to be held on November 9, 2015. The coroner referred Child I for a post-mortem examination at Alder Hey Children’s Hospital. The post-mortem concluded that Child I died of natural causes and as such no inquest was necessary.
Child I’s death was the fifth death in under five months.
It appears to have been the death of Child I in October 2015 that first led Dr Stephen Brearey to raise, in writing, his concerns about Letby, the inquiry hears.

12:06pm
Dr Brearey contacted Eirian Powell, the ward manager, about the events.
The response, on October 23, 2015, subject title 'mortality 2015', was:
“Just to say that I have discussed the above with Anne Murphy and on reflection it was decided to leave this until Monday.
"Alison Kelly [the Director of Nursing and Quality] was not in the hospital and Sian [Sian Williams, the Deputy Director of Nursing] had just left as was not well.
"I have devised a document to reflect the information clearly and it is unfortunate that she [Letby] was on – however each cause of death was different, some were poorly prior to their arrival on the unit and the others were ?NEC or gastric bleeding/congenital abnormalities.
"I have attached the document for your perusal.
"See you Monday – I will discuss further with Debbie on Monday.”

12:07pm
In spite of the views of Ms Powell and Ms Debbie Peacock (Risk & Patient Safety Lead) it seems that by October 2015, Dr Brearey was sufficiently concerned to pursue a more detailed investigation of the unexpected deaths on the unit, the inquiry hears.

Live: Thirlwall inquiry into Lucy Letby baby deaths case begins
 
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12:11pm
Ms Langdale explains there was a Cheshire and Merseyside Neonatal Network Clinical Effectiveness Group meeting on November 12, chaired by Dr Subhedar, a neonatologist from Liverpool Women’s Hospital NHS Foundation Trust, and attended by Ms Powell and Dr Brearey, where it appears neonatal deaths were not discussed in any detail.
In November 2015 a report entitled “Review of neonatal deaths and still births at Countess of Chester Hospital – January 2015 to November 2015” was completed.
This report by Dr Sara Brigham, a consultant obstetrician and gynaecologist at the hospital, looked at stillbirths and neonatal deaths during 2015.
However, this review was from an obstetric perspective. Dr Brearey, the neonatal clinical lead was not even aware that this review was taking place at the time, and was only sent a copy of the report after he requested a copy in late December 2015.
The background section set out that the report was in response to a perceived increase in the number of stillbirths and neonatal deaths at the hospital and that a panel had been set up to independently review all of the cases to identify any common themes, trends and lessons to be learnt.
Despite the misleading title, which referred to the report as a review of neonatal deaths and still births, neonatal care of the babies who died on the unit in 2015 was not examined within the Dr Brigham review.
Dr Brigham's inquiry statement said she was asked to undertake a thematic review of obstetric and maternal care, which (therefore) did not involve the neonatal team.

12:16pm
Ms Langdale moves to the case of Child J. The jury was unable to reach a verdict on a charge of attempted murder.
At this time, there were two further deaths of babies in the neonatal unit. These were not on the trial indictment, and these took place in December 2015 and January 2016.
A thematic review was held on neonatal mortality in February 2016, when Dr Brearey noted it was "significant" that many of the collapses took place between midnight and 4am. He said if these were all down to natural causes, these would be expected to happen throughout the day. Letby was not named in the review.

Live: Thirlwall inquiry into Lucy Letby baby deaths case begins
 
12:11pm
Ms Langdale explains there was a Cheshire and Merseyside Neonatal Network Clinical Effectiveness Group meeting on November 12, chaired by Dr Subhedar, a neonatologist from Liverpool Women’s Hospital NHS Foundation Trust, and attended by Ms Powell and Dr Brearey, where it appears neonatal deaths were not discussed in any detail.
In November 2015 a report entitled “Review of neonatal deaths and still births at Countess of Chester Hospital – January 2015 to November 2015” was completed.
This report by Dr Sara Brigham, a consultant obstetrician and gynaecologist at the hospital, looked at stillbirths and neonatal deaths during 2015.
However, this review was from an obstetric perspective. Dr Brearey, the neonatal clinical lead was not even aware that this review was taking place at the time, and was only sent a copy of the report after he requested a copy in late December 2015.
The background section set out that the report was in response to a perceived increase in the number of stillbirths and neonatal deaths at the hospital and that a panel had been set up to independently review all of the cases to identify any common themes, trends and lessons to be learnt.
Despite the misleading title, which referred to the report as a review of neonatal deaths and still births, neonatal care of the babies who died on the unit in 2015 was not examined within the Dr Brigham review.
Dr Brigham's inquiry statement said she was asked to undertake a thematic review of obstetric and maternal care, which (therefore) did not involve the neonatal team.

12:16pm
Ms Langdale moves to the case of Child J. The jury was unable to reach a verdict on a charge of attempted murder.
At this time, there were two further deaths of babies in the neonatal unit. These were not on the trial indictment, and these took place in December 2015 and January 2016.
A thematic review was held on neonatal mortality in February 2016, when Dr Brearey noted it was "significant" that many of the collapses took place between midnight and 4am. He said if these were all down to natural causes, these would be expected to happen throughout the day. Letby was not named in the review.

Live: Thirlwall inquiry into Lucy Letby baby deaths case begins
What ????
 
12:18pm
Ms Langdale KC adds: "It is clear that both Mr [Ian] Harvey [medical director] and Ms [Alison] Kelly [director of nursing and quality] at the very least knew that the mortality rate on the Neonatal Unit had increased in 2015.", via correspondence on February 2016.

12:21pm
Ms Langdale KC turns to the case of Child K, where Letby was found guilty of attempted murder on a retrial.
A new version of the thematic review was made in March 2016. Letby was still not named. Dr Brearey explained: “I knew the report was going to be widely shared and I thought that this fact was a concern that was better discussed confidentially with the Executives, who I was expecting to meet soon. I also thought Eirian Powell might raise objections if it was included. In retrospect, I regret this decision.”
It is clear Dr Brearey still held concerns. As well as circulating his report to fellow consultants, Dr Brearey also sent an email to Ms Powell on the same date, copying in Dr Ravi Jayaram, saying: “I think we still need to talk about Lucy – maybe when you are back and free the three of us can meet to talk about it?”
Dr Jayaram says that this proposed meeting between the three of them never took place.
However, from November 2015, Dr Jayaram says he had had several “corridor conversations” with both Dr Brearey and other consultant colleagues about his concerns.

12:23pm
On April 1, 2016, Ms Kelly took action in relation to the thematic review and contacted Mr Harvey suggesting a meeting with Dr Brearey and Ms Powell in “early May”. That happened on May 11.
Between March and May 2016, Letby was moved to day shifts, and she attacked Child L and Child M.

12:24pm
Eirian Powell, in a statement to police, said of Letby's move to day shifts on April 7, 2016: “It was my decision to bring Lucy off night shifts for two reasons really, as if what Steve and the others were intimating we needed to have more eyes watching as well, to make sure Lucy was alright and also to make sure there was no wrong doing anywhere.
"There was nothing specific put into place when we changed Lucy to day shifts, as we didn’t want to change anything we just wanted to support her, it wasn’t meant to be a punishment but a support system in place.”
Dr Brearey states that he was not informed of this decision at the time and only learnt of it in May 2016.
Similarly, Ms Kelly, Letby’s overall line manager as Director of Nursing, says she was not told about this change until May 4, 2016.
The decision to put Letby on day shifts was supported by Ms Karen Rees, Head of Nursing Urgent Care Division. In her statement to the inquiry, she said: "I supported Eirian Powell’s decision as there were more staff on day duty so Letby’s clinical practice could be observed more closely.”

12:25pm
Ms Langdale KC tells the inquiry: "The decision to move Letby to day shifts raises serious questions which we will be investigating. If there was sufficient concern to take Letby off night shifts, then how could a decision that left Letby in sole charge of neonatal babies during the day be justified? Who was consulted about this decision?"
She adds that Letby was found guilty of attacking Child L and Child M, having worked day shifts, and it appeared due to staff shortages, Letby did in any event continue to work some night shifts, working a string of four night shifts at the end of May/beginning of June 2016.

Live: Thirlwall inquiry into Lucy Letby baby deaths case begins
 
12:28pm
Ms Langdale moves to the cases of twins Child L and Child M.
Dr Gibbs says that the insulin record was on Child L’s notes and the failure to recognise the potential significance of the result was “a collective failure on the part of us paediatricians” and that the“ our failure to recognise the potential significance of the insulin results in Child L (just as earlier in Child F) meant that an important opportunity was missed to identify, and thus try to prevent, harm to patients in the NNU.”
Mr Harvey said in his statement, regarding Child L's insulin result: “There should have been cross reference with Child F. I think if this had been identified and reported, it would have influenced our decision to go to the police.”

12:30pm
Ms Langdale tells Lady Thirlwall: "There is little by way of review or report of unexpected collapses where the baby survived.
"And yet the Clothier Report recommended over 30 years ago now that reports of serious untoward incidents to District and Regional Health Authorities should be made in writing and through a single channel which is known to all involved.
"Had there been greater consideration of non-fatal unexpected collapses, it seems likely the extent of the correlation between Letby’s presence and the deterioration of babies would have been more apparent and the significance of the unusual rash and the number of unexpected collapses would have been highlighted at an earlier stage."

12:31pm
Dr Brearey, in his inquiry statement, said: "So much focus on mortality throughout 2015 and 2016 did mean that we had very little time to consider and review morbidity (babies who did not die).
"Much of this morbidity evidence, if time allowed us to review it thoroughly, might have led to earlier action being taken.
"Better support from the Trust, particularly the Risk and Patient Safety Department, and more time allocated to my risk role away from my clinic duties might have given me or my colleagues more time and space to consider important morbidity cases.”

Live: Thirlwall inquiry into Lucy Letby baby deaths case begins
 
12:34pm
Ms Langdale also refers to delays in the thematic review being heard. It was not discussed in the May or June 2016 meetings.
Dr Brearey sent a message to Ms Kelly prior to the May 11 meeting: “There is a nurse on the unit who has been present for quite a few of the deaths and other arrests.
"Eirian [Powell] has sensibly put her on day shifts only at the moment, but can’t do this indefinitely.
"It would be very helpful to meet before she is due to go back on night shifts. There is some pressure regarding staffing numbers with this at the moment. Best wishes, Steve."
This is the first occasion which the Inquiry has identified to date, that a member of the Executive Directors Group was informed in writing that the concern about a nurse had resulted in a member of staff’s shift pattern being adjusted.

12:35pm
Within four minutes of receipt, Ms Kelly had forwarded Dr Brearey’s email to Ms Rees, copying in Ms Sian Williams, Deputy Director of Nursing, with the following message:
“Aah!! Can you please look into this with Anne M/Eirian – if there is a staff trend here and we have already changed her shift patterns because of this, then this is potentially very serious!! I will check the report they sent through – I did not notice there was a staff trend!!"
Less than two hours later, Ms Kelly again emailed Ms Rees. At 6.04pm she wrote: “Hi Karen Please see attached (not sure you will have had previous sight of this), Lucy Letby highlighted in red!! I have not noticed this when I first reviewed. Can you please look into this as per my previous email…”
Ms Kelly has told the inquiry she was “quite alarmed” when she typed this email as she “assumed that the shift patterns had been changed as a direct result of the staffing trend identified.”

Live: Thirlwall inquiry into Lucy Letby baby deaths case begins
 
12:36pm
Prior to the May 11 meeting, there was a document produced by Ms Powell, dated May 5, 2016, which starts: “There is no evidence whatsoever against LL [Lucy Letby] other than coincidence. LL works full time and has the Qualification in Speciality (QIS). She is therefore more likely to be looking after the sickest infants on the unit. LL also avails herself to work overtime when the acuity or unit is over capacity.”

12:38pm
On May 6, 2016, Ms Kelly forwarded Dr Brearey’s email about the shift changes of Letby to Mr Harvey. In the body of her email, Ms Kelly wrote:
“Hi Ian, Please see Steve’s comments below which alarmed me!! Since receiving this I have asked Karen Rees to liaise with Eirian regarding this particular nurse (Eirian’s further review is attached for info), I am currently reassured that there are no issues but I think this is worthy of a wider review hence our planned meeting.
"This has been arranged for next Wed to review all the issues with us. Something we need to discuss at our 121 on Monday! Thanks, Alison”
Ms Kelly said in her inquiry evidence she could "recall Karen Rees conveying to me that Eirian did not feel that there were any issues of concern with Letby and that she had changed her shift for reasons connected to her well-being, rather than anything more serious.”

Live: Thirlwall inquiry into Lucy Letby baby deaths case begins
 
Eirian Powell, in a statement to police, said of Letby's move to day shifts on April 7, 2016: “It was my decision to bring Lucy off night shifts for two reasons really, as if what Steve and the others were intimating we needed to have more eyes watching as well, to make sure Lucy was alright and also to make sure there was no wrong doing anywhere.

Ms Kelly said in her inquiry evidence she could "recall Karen Rees conveying to me that Eirian did not feel that there were any issues of concern with Letby and that she had changed her shift for reasons connected to her well-being, rather than anything more serious.”
Too many spanners in the toolbox
 
12:39pm
Notes from the May 11 meeting include the comments “absolute no issues with nurse” and “circumstantial”.
Dr Brearey said: “I highlighted that there seemed to be a disproportionately high number of sudden unexpected collapses. We had reviewed care on multiple occasions, including with an external neonatologist, and the only common theme was the association with [Letby] being on duty. We needed guidance and help on how to take this forward. I also made it clear these were concerns of my colleagues and were not mine in isolation.”
Ms Kelly described Ms Powell being vociferous at this meeting, saying that there were no issues with Letby whatsoever. Dr Brearey gives a similar account, noting that: “Eirian Powell was very defensive of [Letby] at the meeting.”
Mr Harvey recalled of the meeting: "The tone of the meeting was calm and I don’t recall anyone being aggravated or forthright about a concern about Letby."

12:41pm
Ms Langale KC tells the inquiry: "This is an important meeting and the inquiry will be examining closely the accounts from different witnesses about what was said, what was decided and upon what basis.
"Whether deliberate harm had been caused to babies by the nurse they had identified as having an opportunity to do so could only be understood by detailed, forensic investigation and medical analysis of deaths and collapses on the unit.
"Instead of ensuring that in-depth analysis was undertaken, however, the focus appears to have rested upon the superficial - why Letby was present ('the hours she worked'), what staff may have thought of her at the time, and the fact that coincidences can (and clearly do) occur."
Mr Harvey said: "…we were dealing with a spike in deaths on the NNU which were unexplained despite thorough review, and ...we were reassuring Dr Brearey we, the Executives, were aware and supported the actions being undertaken by the clinical team.
"At no stage during this meeting did I feel that it was being reported because there was worry that Letby was responsible for the deaths.
"Based on the information provided at the meeting, there was nothing at all to justify an immediate suspension of Letby.
"Had I been told that she had been seen doing anything that compromised the safety of any patient or that there was evidence of potential intentional harm being caused to any of the babies I would have immediately moved to have her suspended from the unit.”

12:42pm
Ms Kelly recorded in her notes of this meeting at the time that the Action Plan which was agreed was that a review would be conducted of any further babies who suddenly collapsed or deteriorated; to conduct a further deep dive into neonatal deaths which had taken place during the night and have a follow up meeting in July.
Ms Kelly’s notes are in contrast to Dr Brearey’s recollection that other than meeting again in 2 months, there seemed no actions from the meeting. Dr Brearey has told the inquiry he felt that the response from Mr Harvey and Ms Kelly was inadequate.

12:43pm
Dr Brearey sent an email on May 16, 2016 to his fellow paediatric consultants.
He wrote: "If you do come across a baby who deteriorates suddenly or unexpectedly or needs resuscitation on NNU, please could you let me and Eirian know. We will keep a record of these cases and review them as soon as practicable.”
According to Ms Powell’s interview, given as part of Letby’s grievance process, there was an urgent care meeting on May 16, 2016, at which Dr Brearey intimated that he thought a member of staff was causing the increase in mortality.
It was at this meeting there was allegedly reference to there being “a murderess on the neonatal unit.”

12:45pm
The inquiry is now adjourning for a lunch break, after a lot of ground has been covered this morning.

Live: Thirlwall inquiry into Lucy Letby baby deaths case begins
 

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