UK - Lucy Letby - Post-Conviction Statutory Inquiry

[katydid23]

What have we heard this week?​

As the inquiry finishes for the week let's recap the main development of the last few days.

Day 1

• The "tenacious lobbying" of senior consultants may have prevented Lucy Letby from attacking more babies, but "significant opportunities" were missed to investigate her, the inquiry heard

Day 2

• Junior doctors referred to Lucy Letby as "Nurse Death", and paediatricians thought Letby was "the common denominator" in increased baby deaths on the neonatal ward
• Nicholas de la Poer KC said Letby had attempted to murder one of the babies during a hospital inspection at Countess of Chester Hospital

Day 3

• Babies' breathing tubes were found to have been dislodged at an unusual rate during Letby's placements at Liverpool Women's Hospital - Richard Baker KC said this occurs in less than 1% of shifts, but there were recorded incidents of this on 40% of the shifts Letby worked
• Baker told the inquiry that people who doubted her guilt "should be ashamed of themselves"

Day 4

• NHS managers said they were "truly sorry" for delay in contacting police over Letby and NHS England said it "could have done more to scrutinise the hospital" during the time it first became aware of the rise in neonatal mortality figures and when the police became involved

 

[katydid23]

• 
  "Nicholas de la Poer KC said Letby had attempted to murder one of the babies during a hospital inspection at Countess of Chester Hospital"

I didn't really put this together until now---apparently the attempted murder of Baby K happened during a formal inspection of CoC ---Did Letby know the inspectors were there?

ETA---YES, apparently Lucy did know they were there?



We're now hearing from Jenni Richards KC, who is speaking on behalf of the regulator for health and social care providers, the Care Quality Commission (CQC).

She is running through the details of the inspection which the CQC made at the hospital in 2016 - during the time window of Letby’s crimes.

As a reminder, Letby has been convicted of attempting to murder a baby girl, baby K, in the early hours of the morning of the second day of the CQC inspection.

 

[Sweeper2000]

She really couldn't stop herself could she?

 

[katydid23]

Ok, so to refresh our memories of Baby K situation:

Lucy Letby guilty of trying to kill baby

The baby's family say they have been forced to endure a "long, torturous and emotional journey - twice".

www.bbc.com

The jury agreed that the former nurse had dislodged the baby’s breathing tube and stood by her incubator watching her blood oxygen levels drop, without intervening.

Consultant paediatrician Dr Ravi Jayaram had caught her "virtually red-handed" as he entered the unit's intensive care room at about 03:45.

Dr Jayaram, who intervened to resuscitate the child, told jurors he saw "no evidence" that Letby had done anything to help the deteriorating baby.

He said he heard no call for help from Letby, or alarms sounding as Baby K's blood oxygen levels suddenly dropped.

Letby told the jury of six women and six men she had no recollection of any such event.


[so while the Care Quality Commission (CQC) was actively inspecting the level of care in CoC, Nurse Letby quietly dislodged a breathing tube in Baby K's pod, and stood silently, waiting for her to run out of oxygen???]

 

[Parker Knoll]

Yes - she was sabotaging at that very point.
Incredible.

 

[katydid23]

Yes - she was sabotaging at that very point.
Incredible.

And I'm certain that all staff would have been told the inspectors were sniffing around, so everyone has to be very careful and follow all regulations, etc....and her strongest impulse is to dislodge another breathing tube.

 

[Parker Knoll]

You couldn’t make this up.

 

[Tortoise]

[ oh oh, as Senior Management begins their excuse-making, I hope it doesn't become 'evidence' for the LucyIsInnocent crowd.]​

​

​

Letby regarded as a 'good and competent nurse​

​

Judith Moritz
Reporting from the inquiry

Blackwell is now addressing the frequency of infant mortality while Letby was working.
Senior managers were aware that she had had been on shift when "a number of deaths occurred for some time", she says, adding that Letby had specialist training which meant she was more likely to be with the sickest patients on her own.
She "showed her willingness to work extra shifts," she adds.

“The neonatal unit manager Eirian Powell was firmly of the view that Letby was a good and competent nurse.”

“The Senior Managers believe that, given the information with which we were provided, and the need to maintain an open mind about possible causes of the mortality rates on the NNU, we acted appropriately at the time.”

Blackwell says the managers believe they made "reasonable decisions" and were held to account by the hospital board and CEO.

No, they made TERRIBLE decisions, not reasonable decisions. This just makes me furious, that they are defending their actions, when they dismissed the worries of senior medical practitioners with decades of experience, and threatened sanctions, risked the lives and health of the babies, because they were more concerned about LL. They were pushing for her return until the very last minute.

I don't even believe the reason given for moving LL to dayshifts, saying it was to provide LL with more support, and "not a punishment". What sort of answer is that? I believe EP did it in response to the doctors noticing a pattern of it happening at night, and setting out to prove them wrong. But admitting that would mean they were defiant, protective of a murdering nurse, and have blood on their hands for all the babies after baby K, IMO.

This inquiry demands candour! What a sorry bunch they are.

IMO

 

[Tortoise]

And I'm certain that all staff would have been told the inspectors were sniffing around, so everyone has to be very careful and follow all regulations, etc....and her strongest impulse is to dislodge another breathing tube.

Letby messages a colleague about the unit being a "hive of activity" on February 16 in preparation for a visit from "the big bods", and there is a discussion on the possible of delivery of Child K.
Letby mentions one colleague had suspected conjuctivits, but had still come into work, and adds "Hope I haven't caught anything".
Said colleague had also not "done anything but moan" that day, Letby says.
Letby messages the ill colleague saying she hopes that colleague is felling better soon. The colleague responds she was felling better after a day of bed rest, and thanks Letby for her message.

Recap: Lucy Letby trial, Monday, February 27

 

[Tortoise]

A sober fact-finding exercise - or an adversarial battleground?​

13:04 BST​

Judith Moritz
Reporting from the inquiry

This week has given us a snapshot impression of the months to come.

The opening statements at any public inquiry are where you first hear those involved set out their stalls - giving a taste of their headline positions on significant issues, before witnesses start coming to give their evidence.

It’s already clear to me that this is an inquiry which will see different key players banging heads against each other.

Lawyers for the babies’ families didn’t hold back in their criticism of the senior managers at the hospital, accusing them of dishonesty, and a coverup which they suggest appears to have been motivated by the need to protect reputations.

The senior managers have dismissed this suggestion outright as being illogical - saying they didn’t prioritise the reputation of the hospital trust at any time.

They’ve hinted that they’re likely to criticise the consultants on Lucy Letby’s unit - asking why they didn’t contact the police, the nursing regulator or other external bodies directly.

Everyone who’s spoken this week has said that they support the inquiry, and the need to learn lessons.

It will be interesting to see whether that shared aim means that the hearings are a sober fact-finding exercise, or whether they become an adversarial battleground.

• You can follow all the updates to the inquiry here, and a here is a reminder of Lucy Letby's court case.

Lucy Letby hospital inquiry: NHS bosses 'truly sorry' for delay in contacting police over Letby, inquiry hears

 

[Baby baby Jane]

She finishes by saying this was not something ever expected to occur on a neonatal ward, "it being so against the natural order of what was contemplated or foreseen”.

100%
In this ward, who could even consider a colleague - Consultant or Nurse, consciously deciding to harm the most vulnerable of all possible patients? Deliberate harm/murder would be last possible “cause” that would be considered … pre-LL.

 

[Sweeper2000]

Anyone got any ideas as to why the docs didn't contact the police? I'm guessing they got bogged down in a adversarial dynamic, doc's vs managers. Anyone know if they did say to the managers "we will call the fuzz if you dont"?

ETA also true to say that each time the managers rebuffed the docs, the doubt about it would increase and increase the amount of time to take action.

 

[Marantz4250b]

*Managers hope inquiry will operate 'with an open mind'​

She adds she hopes the inquiry will "scrutinise" the complex facts of the case "unblinkered by hindsight bias, and with an open mind".

**NHS managers say inquiry should help lessons to be learned​

Kate Blackwell KC says the NHS senior managers have furnished the inquiry with extensive witness statements - running into hundreds of pages, and have done so willingly.

She says they hope that this inquiry will fulfil its terms of reference fully and for the first time produce a comprehensive account of what happened at the Countess of Chester hospital so that lessons are learned.

* Translation = we know that we're absolutely ****** here so please be kind!

And the statement that they hope that the enquiry will "...operate with an open mind..." is deeply disrespectful and insulting, imo, as it presents the suggestion that it may not do.

** IMHO - Public officials (including politicians) should be barred, on pain of death, from ever issuing a statement using the word "lesson" or any derivative or variant thereof. It's a universal cop out, the translation of which = so, that's all out of the way, nothing to see here because it'll never happen again as we've learned from it and will never repeat it. Which is always absolute b******s, quite frankly!

Didn't they use the same words after Allitt?

It never changes, lessons are never learned and the same awful stuff keeps happening. Nothing will ever change until such time that public officials and managers in safety critical roles stat going to jail when this stuff happens. And I don't mean the lower management directly superior to the malignant staff members. I mean the senior managers who clearly never take responsibility despite being fully aware of the circumstances.

I read somewhere a suggesting that people who are in senior public service management positions should be specifically licensed to carry out the role. Sounds like a very good idea to me.

 

[Marantz4250b]

Interesting. I can easily agree with this. How often is it that we get a baby killer working on units like this? Virtually never so it's only with exceptional rarity that institutions get the chance to learn, adapt and tailor guidelines to it. Same principle applies to staff on the unit concerned, you just wouldn't assume its someone until the results are undeniable.

The thing is that it's not about making an assumption. LL caused grave concerns to doctors and consultants for a significant amount of time before any action was taken. Management were asked time and time again to do something. They didn't.

And, yes, I agree that nurses murdering and harming patients is very rare. It's not unknown, however, and we've had a fair number over the past, say, 25 years or so since Allitt. I would be willing to bet that there have been a fair number struck off over those years for everything ranging from incompetence to actively harming patients, and NHS/Hospital managers should be alert to this type of thing. It's part of the job to spot incompetent nurses, surely?

 

[Marantz4250b]

She finishes by saying this was not something ever expected to occur on a neonatal ward, "it being so against the natural order of what was contemplated or foreseen”.

100%
In this ward, who could even consider a colleague - Consultant or Nurse, consciously deciding to harm the most vulnerable of all possible patients? Deliberate harm/murder would be last possible “cause” that would be considered … pre-LL.

Maybe but something was clearly happening. Even if murder was the furthest thing from you mind you still need to investigate and try to get to the bottom of it. You don't just dismiss because murder is extremely unlikely. It could be that she was grossly incompetent or just reckless.

When consultants (plural) come to you and express concerns about another staff member you need to take that seriously, even if only to show them they're wrong and put their minds at ease.

 

[Marantz4250b]

And I'm certain that all staff would have been told the inspectors were sniffing around, so everyone has to be very careful and follow all regulations, etc....and her strongest impulse is to dislodge another breathing tube.

This, to me, plays exactly to her way of thinking; the CQC are in and wouldn't she look just the hero trying to save a dying baby!

Either that or she just got such a massive high from the danger she couldn't help herself.

 

[Marantz4250b]

Anyone got any ideas as to why the docs didn't contact the police? I'm guessing they got bogged down in a adversarial dynamic, doc's vs managers. Anyone know if they did say to the managers "we will call the fuzz if you dont"?

ETA also true to say that each time the managers rebuffed the docs, the doubt about it would increase and increase the amount of time to take action.

From my memories of the trial discussions they were basically in fear of the consequences.

On the second point; yes, I think they did get to that point eventually. The hospital called in the police as they were presented with a no choice situation by the consultants.

When you are placed in the position that your senior staff are going to mutiny if you don't take drastic action (in this case calling in the police) you have to realise that you've seriously messed up!

 

[Sweeper2000]

The thing is that it's not about making an assumption. LL caused grave concerns to doctors and consultants for a significant amount of time before any action was taken. Management were asked time and time again to do something. They didn't.

And, yes, I agree that nurses murdering and harming patients is very rare. It's not unknown, however, and we've had a fair number over the past, say, 25 years or so since Allitt. I would be willing to bet that there have been a fair number struck off over those years for everything ranging from incompetence to actively harming patients, and NHS/Hospital managers should be alert to this type of thing. It's part of the job to spot incompetent nurses, surely?

It's true. The management certainly have questions to answer. However I do see both sides of this. On the one hand management didn't have much to actually go on did they? if a more extensive post M at child C had taken place they would have fixed it but whose responsibility was that? Remember the evidence showed the kids died either by natural means or in line with them so management in reflection of that have not much to go on other than talk. Talk is dangerous.

I never got the impression that any of the staff at all were incompetent and that includes herself. Indeed she was capable of acting like a experienced and competent nurse seemingly all of the time. Part of the problem it seems. In terms of spotting incompetence how to do that when there isn't any signs of it other than her presence?

It was a big part of the trial imo, random catastrophes that had no solid lead other than her being around. Then in retrospect with all the efforts of the police and evidence gathered was a clear pathway to what was going on established.

 

[katydid23]

Anyone got any ideas as to why the docs didn't contact the police? I'm guessing they got bogged down in a adversarial dynamic, doc's vs managers. Anyone know if they did say to the managers "we will call the fuzz if you dont"?

I think the Docs needed the support of the managers to take the case to the cops because the cops don't know anything about the medical reports---and there was really no evidence at the time proving it was murder---let alone that it was Lucy.

It took several years of deep investigation headed by a medical team before an actual arrest could be made.

ETA also true to say that each time the managers rebuffed the docs, the doubt about it would increase and increase the amount of time to take action.

Yes, if they weren't on the same page, the cops wouldn't have been able to do anything but question Lucy. IMO

 

[katydid23]

Maybe but something was clearly happening. Even if murder was the furthest thing from you mind you still need to investigate and try to get to the bottom of it. You don't just dismiss because murder is extremely unlikely. It could be that she was grossly incompetent or just reckless.

When consultants (plural) come to you and express concerns about another staff member you need to take that seriously, even if only to show them they're wrong and put their minds at ease.

Yes, very early on they should have moved her off the floor, maybe give her a role doing something else for just awhile.

Of course, if the collapses stopped during that time, then what would they do?