UK - Lucy Letby - Post-Conviction Statutory Inquiry

[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?

This is where the problem with the Unions come in---although it is nice for each individual worker to have Union support to protect them from unfair treatment, it can also put an unfair bubble around them, and protect them from firing when they should be fired.

 

[katydid23]

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.

Yes, she was very cunning and used sly details to stay under the radar. She changed up the symptoms so it didn't seem like one person causing harm.

Also, premature babies are vulnerable and it is not unusual to lose one very occasionally. So the first couple of times it did not seem that unusual. But she took breaks from killing so things seemed back to normal and then started back up after she couldn't hold back any longer.

I think the only reason she got caught when she did was that she was being compulsive and obsessive about twins and triplets and just couldn't stop herself. She'd try and kill them on back to back nights.

She'd attack a baby, go on a 2 week vacation, then attack again on her first day back. Two weeks with no collapses while she is on vacay---then the day she returns another one goes down.

 

[Sweeper2000]

Yes, she was very cunning and used sly details to stay under the radar. She changed up the symptoms so it didn't seem like one person causing harm.

Also, premature babies are vulnerable and it is not unusual to lose one very occasionally. So the first couple of times it did not seem that unusual. But she took breaks from killing so things seemed back to normal and then started back up after she couldn't hold back any longer.

I think the only reason she got caught when she did was that she was being compulsive and obsessive about twins and triplets and just couldn't stop herself. She'd try and kill them on back to back nights.

She'd attack a baby, go on a 2 week vacation, then attack again on her first day back. Two weeks with no collapses while she is on vacay---then the day she returns another one goes down.

I remember allot of the evidence made Me think if she did it she didn't really try to hide it very well. Before the triplets came along we all thought the unit musof been rife with talk now we know she was called "an angel of death" then the triplets, then she had her house searched with all that jazz and then the "confession" notes. That all made me think she was either reckless or overtaken by whatever was driving it, in the end it was both.11 Allot about what we heard didn't fit with what I thought would be her doing her best to remove evidence of wrongdoing. That was a part of my initial doubts and then baby e came along. Then the bizarreness followed.

 

[Parker Knoll]

It’s all utterly bizarre sweep.
Nothing about her makes any sense whatsoever.

 

[Tortoise]

I'm just reading Peter Skelton KC's (representing some of the families) opening statement, and one of his points is that the families should have been notified as soon as investigations were initiated at the hospital, not when they concluded. One reason, but not the only reason, being that the investigations didn't capture information and questions that only the parents could have given/asked. Baby E's mum's experience comes to my mind, about seeing baby E bleeding and the excuse LL had given for it, but it wasn't recorded by LL in his notes and she hadn't called the doctor to him, so the hospital investigation wouldn't have uncovered that. Information would have been fresher in the mind of the doctor on shift, than it would a few years further down the line. Baby I's mum's evidence also contradicted the nursing notes that LL had made. I'm sure there are other examples.

When I watched Operation Hummingbird's video, the point was made in it (in my own words not theirs) that even at trial there would necessarily be evidence the families would learn that they had never been told before. This, presumably, although I don't think the reason was stated, to keep their evidence untainted.

I'm interested to know what people here think about that aspect. I also wonder, what if the hospital investigations and later the police investigations had found no evidence of foul play?

 

[Baby baby Jane]

This brought to mind an experience I had with my child,ASD & complex disabilities. He was inpatient, for infection, getting IV antibiotics and nurse’s checking at intervals through the day & night. Day nurses were aware of his challenging reactions to some of their checks, I was sleeping in the room, living there 24/7 to help, and made it clear I was to be woken for nurses checks.
First night, 2am, nurse does his checks without waking me. He is startled, combative, nurse upset that she’s been thrashed at. I wake from commotion. After the checks and he’s settled, I talk to her and explain his disability and ask her be sure it’s in notes, request it’s made really clear that they have to wake me so I can help. Seriously, why the F am I sleeping there!!

The next day, a different nurse leaves his file on the table in the room, I flip through it and see the nurse’s interpretation of the event. She says she woke me, I refused to help and she’s been punched by patient. I take out my pen and update her entry with my view of the incident.
I had a visit from a senior admin person to tell me off about writing in the confidential medical notes!! Of course I defended my action and made it clear that the nursing staff were not doing proper handover or note reading. He was ASD, complex child not a passive child who could be woken, prodded and jabbed with no reaction!!

My point, is nurse has a lot of latitude & privacy to write/record whatever he/she likes in her observations. And sr staff there to defend it. Especially if they are effing up treatment, from incompetence, or deliberately.

 

[Anxala]

This brought to mind an experience I had with my child,ASD & complex disabilities. He was inpatient, for infection, getting IV antibiotics and nurse’s checking at intervals through the day & night. Day nurses were aware of his challenging reactions to some of their checks, I was sleeping in the room, living there 24/7 to help, and made it clear I was to be woken for nurses checks.
First night, 2am, nurse does his checks without waking me. He is startled, combative, nurse upset that she’s been thrashed at. I wake from commotion. After the checks and he’s settled, I talk to her and explain his disability and ask her be sure it’s in notes, request it’s made really clear that they have to wake me so I can help. Seriously, why the F am I sleeping there!!

The next day, a different nurse leaves his file on the table in the room, I flip through it and see the nurse’s interpretation of the event. She says she woke me, I refused to help and she’s been punched by patient. I take out my pen and update her entry with my view of the incident.
I had a visit from a senior admin person to tell me off about writing in the confidential medical notes!! Of course I defended my action and made it clear that the nursing staff were not doing proper handover or note reading. He was ASD, complex child not a passive child who could be woken, prodded and jabbed with no reaction!!

My point, is nurse has a lot of latitude & privacy to write/record whatever he/she likes in her observations. And sr staff there to defend it. Especially if they are effing up treatment, from incompetence, or deliberately.

That's awful. What horrible stress on top of the stress you and your son were already under just by being unwell and in hospital. Kudos for not taking any crap from them but it's awful that you and your son were so unnecessarily put in that position.

 

[Sweeper2000]

I'm just reading Peter Skelton KC's (representing some of the families) opening statement, and one of his points is that the families should have been notified as soon as investigations were initiated at the hospital, not when they concluded. One reason, but not the only reason, being that the investigations didn't capture information and questions that only the parents could have given/asked. Baby E's mum's experience comes to my mind, about seeing baby E bleeding and the excuse LL had given for it, but it wasn't recorded by LL in his notes and she hadn't called the doctor to him, so the hospital investigation wouldn't have uncovered that. Information would have been fresher in the mind of the doctor on shift, than it would a few years further down the line. Baby I's mum's evidence also contradicted the nursing notes that LL had made. I'm sure there are other examples.

When I watched Operation Hummingbird's video, the point was made in it (in my own words not theirs) that even at trial there would necessarily be evidence the families would learn that they had never been told before. This, presumably, although I don't think the reason was stated, to keep their evidence untainted.

I'm interested to know what people here think about that aspect. I also wonder, what if the hospital investigations and later the police investigations had found no evidence of foul play?

That doesn't sound right to me. How wre the parents not a part of the investigation? Were they not considered potentially as witnesses who could give information very relevant to the investigation itself? "What did you think of the care your baby received at the hospital"? "Did you see or hear anything you thought was memorable"? Etc I would have thought it was essential to the investigation itself especially when concerns about potential criminal acts are involved. That's a failing if they didn't though, it would have helped to spot discrepancies and maybe to highlight solid irregularities in the relevant info
Such as Baby E mum coming down for the 9pm feed as expected.

They did question the doctors At the time of the investigation surely? Then got the docs opinions on babe E for example? Again I might have thought the potential of criminality would have ensured that? Maybe the hospital looked at things purely through the lens of medicine and then had to rely on notes that had been falsified?

For the part they played I don't think the parents needed to know anything of the investigation though, indeed if it jeopardised the case I can understand however the hospital should have let them know about the essentials. Ie "we are looking at medical files for a range of babies yours included for any reasons for the issues", "we are currently finding it difficult to provide a medical explanation for the issues", "we believe there are issues in the med files that are outside the realms of normal medicine and are referring to the police". I wouldn't have guessed that the hospital qwould seek statements from the parents other than an initial statement about what happened, they would focus on the med files.

Ooooh now gauging what the result of nothing being found would be difficult but I'm most sure that she would have continued until being caught though or maybe even got a job somewhere else and then continued. No way she would ever live that down though shown by her not being very chatty at the tea party reunion.

Does that answer your query thoroughly?

 

[Anxala]

I'm just reading Peter Skelton KC's (representing some of the families) opening statement, and one of his points is that the families should have been notified as soon as investigations were initiated at the hospital, not when they concluded. One reason, but not the only reason, being that the investigations didn't capture information and questions that only the parents could have given/asked. Baby E's mum's experience comes to my mind, about seeing baby E bleeding and the excuse LL had given for it, but it wasn't recorded by LL in his notes and she hadn't called the doctor to him, so the hospital investigation wouldn't have uncovered that. Information would have been fresher in the mind of the doctor on shift, than it would a few years further down the line. Baby I's mum's evidence also contradicted the nursing notes that LL had made. I'm sure there are other examples.

When I watched Operation Hummingbird's video, the point was made in it (in my own words not theirs) that even at trial there would necessarily be evidence the families would learn that they had never been told before. This, presumably, although I don't think the reason was stated, to keep their evidence untainted.

I'm interested to know what people here think about that aspect. I also wonder, what if the hospital investigations and later the police investigations had found no evidence of foul play?

If they had been, they would have been a invaluable asset imo and given compelling weight to the existing concerns.

Imagine listening to the evidence in the trial and only then realising the part your own personal experience might have played in the fate of your child? Horrifying.

 

[Tortoise]

That doesn't sound right to me. How wre the parents not a part of the investigation? Were they not considered potentially as witnesses who could give information very relevant to the investigation itself? "What did you think of the care your baby received at the hospital"? "Did you see or hear anything you thought was memorable"? Etc I would have thought it was essential to the investigation itself especially when concerns about potential criminal acts are involved. That's a failing if they didn't though, it would have helped to spot discrepancies and maybe to highlight solid irregularities in the relevant info
Such as Baby E mum coming down for the 9pm feed as expected.

They did question the doctors At the time of the investigation surely? Then got the docs opinions on babe E for example? Again I might have thought the potential of criminality would have ensured that? Maybe the hospital looked at things purely through the lens of medicine and then had to rely on notes that had been falsified?

For the part they played I don't think the parents needed to know anything of the investigation though, indeed if it jeopardised the case I can understand however the hospital should have let them know about the essentials. Ie "we are looking at medical files for a range of babies yours included for any reasons for the issues", "we are currently finding it difficult to provide a medical explanation for the issues", "we believe there are issues in the med files that are outside the realms of normal medicine and are referring to the police". I wouldn't have guessed that the hospital qwould seek statements from the parents other than an initial statement about what happened, they would focus on the med files.

Ooooh now gauging what the result of nothing being found would be difficult but I'm most sure that she would have continued until being caught though or maybe even got a job somewhere else and then continued. No way she would ever live that down though shown by her not being very chatty at the tea party reunion.

Does that answer your query thoroughly?

Well I was just thinking that if you as a parent were told that the hospital is investigating your child's death or collapse, before any police are involved, (not in this case but in a hypothetical case) without being able to give you any information about what happened, that would signal some suspicion of a failing in care which they weren't yet in a position to confirm or deny. As a parent I would want to know what they were keeping from me, especially if my baby had already had a post-mortem, or had been left brain-damaged as a result of a collapse. Perhaps the parents could be contacted as a final part of the investigation, once there are firmed up suspicions, so that they can inform the investigation more fully.

I should have been clearer that it was a hypothetical question about no foul play being found, not in LL's case, but for recommendations as to how this should be handled in the future.

 

[Ruthbullock]

S

She worked in neonatal from qualifying so had been nursing ET tubes for years when she did her neonatal course at Liverpool

She qualified in 2012 as a nurse, before starting the training for specialist baby care- which she did until late spring 2015, then got a job back at the countess in the NICU after her final training placement at Liverpool. This is the inquiry thread, not the LL trial thread- it’s about looking at what went wrong and where in the much grander scheme of things to prevent this happening again. They were training placements and someone was supervising her on that placement, someone was checking her progress and added on to that they also had an audit that it now appears also should have raised concerns- don’t get too hung up on the trial and the fact that one person is imprisoned and ignore the fact that this could be repeated again tomorrow due to all the other failings that surround her.

 

[Ruthbullock]

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.

You do have to wonder, I’m sure most of them were also in unions and could have got them involved to support and fight a bit stronger.
I also question why when the nurses and doctors behind the desk saw the alarms going off they didn’t react- having had a stay in ICU- if an alarm went off it was checked and switched off via the desk, not at the bed and someone would also come and check you- so effectively there were always two people checking when an alarm went off- the person sat behind the desk would look and check if anything was needed to be done and a second person would be sent to check/ or already be present at the bedside checking in person. They then fed back to each other, with the person behind the desk at that point updating the notes. The understaffing has got to be flagged in the inquiry.

 

[Ruthbullock]

One of the FOi’s
The number of complaints made against Consultants, SHOs, Registrars and Doctors working on the
Neonatal Unit and Paediatric Wards from 2008 to present. No FOI about nurses, and I can think of a few more questions I would like to add to it- including a breakdown between units and years.

https://www.whatdotheyknow.com/request/complaints_regarding_neonatal_an/response/2462201/attach/2/FOI%207442%20Response.pdf?cookie_passthrough=1

 

[Ruthbullock]

They do appear to be more rigorous now- the number of nurse and midwife referrals to the NMC since 2019

https://www.whatdotheyknow.com/request/number_of_nurse_and_midwife_refe_105/response/2634939/attach/2/FOI%207817%20Response.pdf?cookie_passthrough=1

 

[Ruthbullock]

But a refusal to do this FOI: The number of nurses Countess of Chester Hospital NHS Foundation Trust referred to the Nursing and
Midwifery Council in each of the following years: 2012, 2013, 2014, 2015, 2016.

https://www.whatdotheyknow.com/request/nurse_referrals_cch_2012_2016/response/2724187/attach/2/FOI%208189%20Response%20Nurse%20Referrals%20to%20NMC.pdf?cookie_passthrough=1

 

[Ruthbullock]

IMO if they could do it for post 254, they could do it for the following post as they are the same request, just different years- but have not.

 

[JosieJo]

S

She qualified in 2012 as a nurse, before starting the training for specialist baby care- which she did until late spring 2015, then got a job back at the countess in the NICU after her final training placement at Liverpool. This is the inquiry thread, not the LL trial thread- it’s about looking at what went wrong and where in the much grander scheme of things to prevent this happening again. They were training placements and someone was supervising her on that placement, someone was checking her progress and added on to that they also had an audit that it now appears also should have raised concerns- don’t get too hung up on the trial and the fact that one person is imprisoned and ignore the fact that this could be repeated again tomorrow due to all the other failings that surround her.

I absolutely know what thread it is and having worked in the nhs for over 30 years want as much as anyone for the hospital failings to bring about change. I was merely saying she would have worked a lot with intubated babies prior to doing her NICU course at Liverpool