UK - Lucy Letby - Post-Conviction Statutory Inquiry
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Tortoise
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Hearings | The Thirlwall Inquiry
Details of past and scheduled hearings for the Thirlwall Inquiry.
thirlwall.public-inquiry.uk
Hearings | The Thirlwall Inquiry
Details of past and scheduled hearings for the Thirlwall Inquiry.
thirlwall.public-inquiry.uk
Week 3 Oral Evidence
The Inquiry is hearing Part A evidence in private session with no public attendance. Only Thursday 26 September will be open to the public.Registration to attend is now closed.
Hearing dates
23 September 2024Part A evidence – private session
24 September 2024
Part A evidence – private session
25 September 2024
Part A evidence – private session
26 September 2024
Expert Witness, Overview witness on safeguarding and child death processes
JosieJo
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Thanks
Hearings | The Thirlwall Inquiry
Details of past and scheduled hearings for the Thirlwall Inquiry.
Week 3 Oral Evidence
The Inquiry is hearing Part A evidence in private session with no public attendance. Only Thursday 26 September will be open to the public.
Registration to attend is now closed.
Hearing dates
23 September 2024
Part A evidence – private session
24 September 2024
Part A evidence – private session
25 September 2024
Part A evidence – private session
26 September 2024
Expert Witness, Overview witness on safeguarding and child death processes
Tortoise
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I've found a more detailed schedule
thirlwall.public-inquiry.uk
Week 3 – Private Sessions, Expert evidence
Date / Witness(es)| Monday 23 September | Mother and Father J Mother and Father K |
| Tuesday 24 September | Father L & M (to be read) Mother and Father N (to be read) |
| Wednesday 25 September | Mother and Father O, P and R (to be read) |
| Thursday 26 September | Professor Mary Dixon-Woods – Expert witness Dr Joanna Garstang – Overview witness on safeguarding and child death processes |
Witness Timetable | The Thirlwall Inquiry
Examining the events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital.
thirlwall.public-inquiry.uk
Tortoise
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About expert witness - Professor Mary Dixon-Woods
www.thisinstitute.cam.ac.uk
A Professorial Fellow at Homerton College, Cambridge, she is also a fellow of the Academy of Social Sciences and the Academy of Medical Sciences, an honorary fellow of the Royal College of Physicians, the Royal College of General Practitioners, and the Royal College of Obstetricians and Gynaecologists. She was an NIHR Senior Investigator 2017-2022.
Mary served on England’s National Advisory Group on the Safety of Patients in England, which produced the Berwick report in 2013. She also served on the review of information technology in the NHS led by Professor Bob Wachter, which reported in 2016. She was a Wellcome Trust Senior Investigator 2012-2019. Mary was the Harveian Orator for the Royal College of Physicians in 2018, the 500th anniversary of the College’s founding. She is a member of the BMJ’s international advisory board.
Professor Mary Dixon-Woods
www.thisinstitute.cam.ac.uk
Professor Mary Dixon-Woods
Director
Mary Dixon-Woods is Director of THIS Institute and The Health Foundation Professor of Healthcare Improvement Studies in the Department of Public Health and Primary Care at the University of Cambridge.A Professorial Fellow at Homerton College, Cambridge, she is also a fellow of the Academy of Social Sciences and the Academy of Medical Sciences, an honorary fellow of the Royal College of Physicians, the Royal College of General Practitioners, and the Royal College of Obstetricians and Gynaecologists. She was an NIHR Senior Investigator 2017-2022.
Mary served on England’s National Advisory Group on the Safety of Patients in England, which produced the Berwick report in 2013. She also served on the review of information technology in the NHS led by Professor Bob Wachter, which reported in 2016. She was a Wellcome Trust Senior Investigator 2012-2019. Mary was the Harveian Orator for the Royal College of Physicians in 2018, the 500th anniversary of the College’s founding. She is a member of the BMJ’s international advisory board.
Research Interests
Mary’s programme of research is concerned with generating a high quality evidence-base to support improvement in the organisation, quality and safety of healthcare. Characteristically using mixed-methods approaches, her work focuses on evaluation of quality and safety improvement interventions and programmes, culture and behaviour in health systems, and regulation and governance of health research and care. She has a special interest in methodological innovation in the study of healthcare improvement.
Tortoise
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Dr Joanna Garstang
School of Nursing and Midwifery
Clinical Associate Professor of Child Protection
Dr Joanna Garstang is a Clinical Associate Professor and Consultant Community Paediatrician. Her specialist areas are in safeguarding children, Child Death Review and Sudden Unexpected Death in Childhood. Joanna's PhD was an evaluation of multi-agency investigation of unexpected infant death from both the parents' and professionals' perspectives, more recently her research has focussed on improving multi-agency working in safeguarding and preventable child mortality.
Dr Joanna Garstang
School of Nursing and Midwifery
Clinical Associate Professor of Child Protection
Dr Joanna Garstang is a Clinical Associate Professor and Consultant Community Paediatrician. Her specialist areas are in safeguarding children, Child Death Review and Sudden Unexpected Death in Childhood. Joanna's PhD was an evaluation of multi-agency investigation of unexpected infant death from both the parents' and professionals' perspectives, more recently her research has focussed on improving multi-agency working in safeguarding and preventable child mortality.
garstang-joanna
Staff profile for Dr Joanna Garstang, Clinical Associate Professor of Child Protection in the School of Nursing and Midwifery in the Institute of Clinical Sciences.
www.birmingham.ac.uk
Tortoise
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Oh dear, I'm just reading Child H's mother's evidence. She wasn't kept informed by the NNU staff of Child H's condition, or that she had been put on a ventilator, and she wasn't able to leave her ward to get to the NNU without assistance, and EP sent this email to Dr Gibbs about the mother's complaint -
pages 60 - 62 19/09/2024 – Transcript of Week 2 Day 4 | The Thirlwall Inquiry
Q. So it begins with an email from Brenda Hooley, but the Eirian Powell email is towards the bottom of the first page. And there is a reference to your complaint: "Brenda from PALS came to speak to me this lunchtime." Did you formulate your complaint through PALS?
A. Yes, yeah.
Q. And there is a comment from Eirian Powell in the penultimate paragraph to that email which begins: "My question as an addendum ..."; can you see that?
A. Yes, I can.
Q. "... is why it had taken mum so long to come to the unit when she was aware of how poorly her baby is. (just a thought) especially as she is an inpatient, or even ask a midwife to ring/use her mobile for an update. I have spoken to Belinda and Nurse W, and as you can imagine Nurse W is upset that she had tried her best, only to receive this complaint." First of all, what sort of interactions, if any, had you had with Eirian Powell prior to this point?
A. I don't recall many, if I'm being honest, many interactions with her. So I didn't know of her and I certainly don't remember her being involved in our daughter's care at any point. So I know who she is, so now I know she was there and around on the wards at the time, but I certainly don't remember her having any involvement in the care of our daughter at that time.
Q. Had you had any conversations with Eirian Powell before you discovered that Child H was on a ventilator?
A. No.
Q. Reading that comment now, how does that make you feel?
A. Very, very upset, and I am shocked that that is even part of a conversation between the nurse and the doctor, because she hasn't got the full story there at all. And, you know, I am deeply offended by that. You know, like how dare she make a comment on that at such a difficult time? Because in actual fact I was an inpatient on the ward, I had asked many a times for the people up there to phone, to phone down. I had used my mobile to ring to check that she was okay, and I was told that she was stable, and I was trying my best to get down there. I wasn't allowed to just go down on my own, so I couldn't get down there easily. And I wasn't aware of how poorly she was because I wasn't told how poorly she was. So to have been told that she was stable only just before, to then go down and find this situation, and you think: well, what has happened, you know, in the meantime? And to then have somebody comment on it, to say, "Why did it take so long?", when in actual fact I was trying my best to get down there, and nobody had informed me. So if somebody would have told me, I would have been able to have got down there, as well, much quicker. And if the staff weren't so busy up on the ward, then more people would have been able to helped to get down there. There's a massive assumption, I think, being made on her behalf there, but why that even comes into a conversation with regards to a PALS complaint, or it's felt as being appropriate, is deeply upsetting, if that's the view that they're taking of parents. And if she felt like that, as well, why didn't she come to talk to me, to say: "Look, your baby is really poorly, you know, maybe you should spend a bit more time here?" When in actual fact all the nurses were doing was telling me to take more of a break because I was spending so long next to her cot-side, you'd get the impression. So I can't understand how they can say something like that in an email between each other, and have a very different outlook, especially for the fact that I had not spoken to her, she didn't know the situation. And that was exactly our problem: was that we weren't being communicated with to be told how poorly she was.
pages 60 - 62 19/09/2024 – Transcript of Week 2 Day 4 | The Thirlwall Inquiry
Q. So it begins with an email from Brenda Hooley, but the Eirian Powell email is towards the bottom of the first page. And there is a reference to your complaint: "Brenda from PALS came to speak to me this lunchtime." Did you formulate your complaint through PALS?
A. Yes, yeah.
Q. And there is a comment from Eirian Powell in the penultimate paragraph to that email which begins: "My question as an addendum ..."; can you see that?
A. Yes, I can.
Q. "... is why it had taken mum so long to come to the unit when she was aware of how poorly her baby is. (just a thought) especially as she is an inpatient, or even ask a midwife to ring/use her mobile for an update. I have spoken to Belinda and Nurse W, and as you can imagine Nurse W is upset that she had tried her best, only to receive this complaint." First of all, what sort of interactions, if any, had you had with Eirian Powell prior to this point?
A. I don't recall many, if I'm being honest, many interactions with her. So I didn't know of her and I certainly don't remember her being involved in our daughter's care at any point. So I know who she is, so now I know she was there and around on the wards at the time, but I certainly don't remember her having any involvement in the care of our daughter at that time.
Q. Had you had any conversations with Eirian Powell before you discovered that Child H was on a ventilator?
A. No.
Q. Reading that comment now, how does that make you feel?
A. Very, very upset, and I am shocked that that is even part of a conversation between the nurse and the doctor, because she hasn't got the full story there at all. And, you know, I am deeply offended by that. You know, like how dare she make a comment on that at such a difficult time? Because in actual fact I was an inpatient on the ward, I had asked many a times for the people up there to phone, to phone down. I had used my mobile to ring to check that she was okay, and I was told that she was stable, and I was trying my best to get down there. I wasn't allowed to just go down on my own, so I couldn't get down there easily. And I wasn't aware of how poorly she was because I wasn't told how poorly she was. So to have been told that she was stable only just before, to then go down and find this situation, and you think: well, what has happened, you know, in the meantime? And to then have somebody comment on it, to say, "Why did it take so long?", when in actual fact I was trying my best to get down there, and nobody had informed me. So if somebody would have told me, I would have been able to have got down there, as well, much quicker. And if the staff weren't so busy up on the ward, then more people would have been able to helped to get down there. There's a massive assumption, I think, being made on her behalf there, but why that even comes into a conversation with regards to a PALS complaint, or it's felt as being appropriate, is deeply upsetting, if that's the view that they're taking of parents. And if she felt like that, as well, why didn't she come to talk to me, to say: "Look, your baby is really poorly, you know, maybe you should spend a bit more time here?" When in actual fact all the nurses were doing was telling me to take more of a break because I was spending so long next to her cot-side, you'd get the impression. So I can't understand how they can say something like that in an email between each other, and have a very different outlook, especially for the fact that I had not spoken to her, she didn't know the situation. And that was exactly our problem: was that we weren't being communicated with to be told how poorly she was.
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Tortoise
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This was also from Mother H's evidence, pages 42-44 19/09/2024 – Transcript of Week 2 Day 4 | The Thirlwall Inquiry
(my comment - note LL's first arrest was 3 July 2018. I think it's interesting to get a parent's confirmation of exactly what Detective Superintendent Paul Hughes of Operation Hummingbird has said about the initial approach of police. Parts bolded by me.)
Q. When did you learn that there were suspicions and concerns about her and her conduct?
A. May 2017. I got a phone call from the police. We'd seen the newspaper articles at the time that said there were investigations into baby deaths and collapses on the neonatal unit, and they would determine if it was medical negligence or somebody, you know, could have caused harm. But at that point when we were told by the police, we were sort of given the impression that the fact that somebody could have caused deliberate harm was very much a worst-case scenario. And we didn't expect that to happen. I mean, you don't, you just can't imagine that somebody would do that. So we just didn't for a second think that but we did think, you know, we never knew why these collapses happened.
Q. Did you get a telephone call before she was arrested from the police?
A. Yes, yes.
Q. What were you told then?
A. So we were told then that they were going to be making an arrest, because prior to that, we were told that they had -- were going along the route of that somebody that caused harm, and that was quite a shock to take. They couldn't tell us who it was until they were making the arrest, and I remember them saying -- phoning to say they were going to be arresting Lucy Letby. And I remember thinking: how could this -- you know, how could this have happened? It didn't feel real. But at the point that we were told that somebody had caused harm, and there was a high probability, they said that somebody would have caused harm and that's what they were looking into now, the police said. At that stage I didn't know that Lucy Letby was under suspicion. So to get that phone call and say that it was her was definitely a shock, and it was very hard. I remember it being very early in the morning.
Q. When were you and how were you told that Letby was suspected of causing injury to your child, Child H?
A. Well, during that call, because we knew -- well, we knew that somebody -- that there was a high probability that somebody was causing harm because at the first point it was a case of looking at all the options and then we were told that it was a case of -- it was a high probability that they were -- somebody had caused the harm was the reason that they were now looking into. So we knew that there was a potential that somebody had caused the harm. But it still didn't seem definite at that point. And then it was the point that, "We're arresting somebody because -- we have Lucy Letby, who we believe has caused the harm."
(my comment - note LL's first arrest was 3 July 2018. I think it's interesting to get a parent's confirmation of exactly what Detective Superintendent Paul Hughes of Operation Hummingbird has said about the initial approach of police. Parts bolded by me.)
Q. When did you learn that there were suspicions and concerns about her and her conduct?
A. May 2017. I got a phone call from the police. We'd seen the newspaper articles at the time that said there were investigations into baby deaths and collapses on the neonatal unit, and they would determine if it was medical negligence or somebody, you know, could have caused harm. But at that point when we were told by the police, we were sort of given the impression that the fact that somebody could have caused deliberate harm was very much a worst-case scenario. And we didn't expect that to happen. I mean, you don't, you just can't imagine that somebody would do that. So we just didn't for a second think that but we did think, you know, we never knew why these collapses happened.
Q. Did you get a telephone call before she was arrested from the police?
A. Yes, yes.
Q. What were you told then?
A. So we were told then that they were going to be making an arrest, because prior to that, we were told that they had -- were going along the route of that somebody that caused harm, and that was quite a shock to take. They couldn't tell us who it was until they were making the arrest, and I remember them saying -- phoning to say they were going to be arresting Lucy Letby. And I remember thinking: how could this -- you know, how could this have happened? It didn't feel real. But at the point that we were told that somebody had caused harm, and there was a high probability, they said that somebody would have caused harm and that's what they were looking into now, the police said. At that stage I didn't know that Lucy Letby was under suspicion. So to get that phone call and say that it was her was definitely a shock, and it was very hard. I remember it being very early in the morning.
Q. When were you and how were you told that Letby was suspected of causing injury to your child, Child H?
A. Well, during that call, because we knew -- well, we knew that somebody -- that there was a high probability that somebody was causing harm because at the first point it was a case of looking at all the options and then we were told that it was a case of -- it was a high probability that they were -- somebody had caused the harm was the reason that they were now looking into. So we knew that there was a potential that somebody had caused the harm. But it still didn't seem definite at that point. And then it was the point that, "We're arresting somebody because -- we have Lucy Letby, who we believe has caused the harm."
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Tortoise
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[Child J's parents today: ]
The child’s mother described finding her six-week-old daughter in a cot with her stoma removed and her lower half covered loosely with a soiled towel. [...]
Child J’s father said the couple made a complaint the same day about their daughter being left “covered in her own faeces” but were told by a nurse that they were “tired and stressed and we should consider going home”. <mod edit: quoted article updated>
He said they found this “quite annoying” and “condescending”. His partner added: “They didn’t really own what had happened. That was quite frustrating really – that it got turned – that it was us that were the challenge.”
Child J’s parents said they were never told the result of this complaint and learned only recently, eight years later, that Letby had been their daughter’s designated nurse on that shift on 15 December 2015.
[...]
www.theguardian.com
The child’s mother described finding her six-week-old daughter in a cot with her stoma removed and her lower half covered loosely with a soiled towel. [...]
Child J’s father said the couple made a complaint the same day about their daughter being left “covered in her own faeces” but were told by a nurse that they were “tired and stressed and we should consider going home”. <mod edit: quoted article updated>
He said they found this “quite annoying” and “condescending”. His partner added: “They didn’t really own what had happened. That was quite frustrating really – that it got turned – that it was us that were the challenge.”
Child J’s parents said they were never told the result of this complaint and learned only recently, eight years later, that Letby had been their daughter’s designated nurse on that shift on 15 December 2015.
[...]
Parents found baby under Lucy Letby’s care covered in faeces
Inquiry into murder of babies at the Countess of Chester hospital hears about newborn girl fitted with stoma
Last edited by a moderator:
That reference to <modsnip: Name redacted> has now been removed and replaced with 'a nurse'. The Guardian note reads:[Child J's parents today: ]
The child’s mother described finding her six-week-old daughter in a cot with her stoma removed and her lower half covered loosely with a soiled towel. [...]
Child J’s father said the couple made a complaint the same day about their daughter being left “covered in her own faeces” but were told by a nurse that they were “tired and stressed and we should consider going home”. <mod edit: quoted article updated>
He said they found this “quite annoying” and “condescending”. His partner added: “They didn’t really own what had happened. That was quite frustrating really – that it got turned – that it was us that were the challenge.”
Child J’s parents said they were never told the result of this complaint and learned only recently, eight years later, that Letby had been their daughter’s designated nurse on that shift on 15 December 2015.
[...]
Parents found baby under Lucy Letby’s care covered in faeces
Inquiry into murder of babies at the Countess of Chester hospital hears about newborn girl fitted with stoma
' This article was amended on 24 September 2024. An earlier version included the name of a nurse at the Countess of Chester hospital to whom the parents of Child J said they had complained regarding the condition in which their baby was left in her cot. At the opening of proceedings on 24 September, Rachel Langdale KC told the inquiry the parents had misidentified that nurse <modsnip: Name redacted> and were correcting their evidence. The identity of the nurse would be explored in further evidence, she said.'
Parents found baby under Lucy Letby’s care covered in faeces
Inquiry into murder of babies at the Countess of Chester hospital hears about newborn girl fitted with stoma
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Sweeper2000
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One thing I will say is that it doesn't sound like Lucy.
Tortoise
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Tortoise
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Baby N’s father told the Thirlwall Inquiry, sitting in Liverpool, that he had been ‘horrified’ to hear during Letby’s criminal trial how staff discussed the babies they were looking after in messages on Facebook and via texts on their private mobile phones. [...]
Baby N’s mother also said Dr U had shared e-mails exchanged between consultants about Letby’s conduct with her, which was wrong.
She said she had made a formal complaint about him to the hospital where he now works at the end of the criminal trial last August and the investigation is ongoing.
‘I do not object to nurses and doctors discussing patients, (but) it’s the method of communication by insecure means and the breach in confidentiality that was so wilfully ignored and commonly used by a number of staff,’ she said. ‘If they had paid more attention to their patients, rather than gossiping, things might have been different.’ [...]
www.dailymail.co.uk
Baby N’s mother also said Dr U had shared e-mails exchanged between consultants about Letby’s conduct with her, which was wrong.
She said she had made a formal complaint about him to the hospital where he now works at the end of the criminal trial last August and the investigation is ongoing.
‘I do not object to nurses and doctors discussing patients, (but) it’s the method of communication by insecure means and the breach in confidentiality that was so wilfully ignored and commonly used by a number of staff,’ she said. ‘If they had paid more attention to their patients, rather than gossiping, things might have been different.’ [...]
Lucy Letby bosses should face criminal charges, mother tells inquiry
The nurse tried to murder her son, a premature baby boy, in June 2016 - almost a year after consultants say they first flagged the link between Letby and a spike in deaths
JosieJo
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The mobile phone use seemed excessive on the unit...whether it was just LL using her phone to that extent or it was widespread?
Dr U certainly should be investigated..is that something that should be made public anyone know?
Dr U certainly should be investigated..is that something that should be made public anyone know?
Sweeper2000
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How do the nurses on here feel about having cctv on every patient under care? Seems unnecessary to me as this kind of thing is so rare and also feels like everyone is getting tarred with the demonic beige Lucy letby brush and that's a horrendous colour. It's the colour you get in between bleach blonde and mouse brown.
iamshadow21
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Health care serial killers are rare, yes, but abusers are everywhere. Just look at how many babysitters and care home workers have been caught abusing their charges with things like nanny cams.
It would even work the other way - if an abuser assaults a family member patient, it would be on camera, too.
It's about patient safety. I can see the benefits.
But like anything, the potential for abuse is there, too, whenever vulnerable people are filmed.
MOO
JosieJo
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I'm not a fan of cameras directly on patients due to privacy but I feel there is a place for more cameras in ward corridors , nurses stations , drug treatment rooms etc
Tortoise
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I'm going to say that it's not a great idea. For one, the camera in the cot would be on the baby, not the nurse or the drip stand, or the monitor equipment being paused. Secondly, apart from the overt physical assaults in this case, which are highly unusual even in nurse serial killer cases, and the tube dislodgements, it probably wouldn't have shown an air bubble travelling through a tiny line into the UVC or other taped in catheter, partially obstructed by tape, a nappy or a blanket, and it wouldn't have shown insulin already mixed in with TPN. Thirdly, I think it's fine to think a baby sleeping or being cute would be something a mother on a different ward would want to watch, but the times (not harm events) when a baby is in distress and having breathing difficulties, perhaps crashing and having CPR, would be very distressing to watch remotely. Then there is the problem with other patients on the mother's ward being able to watch your baby when you are not in your bed. And the mothers who have been discharged not having hospital cctv at home. And babies being moved from one nursery to another or one incubator to another, and the potential for the wrong baby to be transmitted to the wrong mother.
I think the serial killer nurse is always going to find a way to do harm, knowing what the cameras capture and don't capture. I think what went wrong in this case could be prevented with a better system of flagging up unexpected events, and communication of that to all senior team members, adhering to rules about two person procedures, and regular training and preparedness to think anybody, whatever impression you have of them, could be causing deliberate harm, or independent and rapid evaluation of serious incidents from an outside agency, who does not know the personnel at the hospital.
I think the serial killer nurse is always going to find a way to do harm, knowing what the cameras capture and don't capture. I think what went wrong in this case could be prevented with a better system of flagging up unexpected events, and communication of that to all senior team members, adhering to rules about two person procedures, and regular training and preparedness to think anybody, whatever impression you have of them, could be causing deliberate harm, or independent and rapid evaluation of serious incidents from an outside agency, who does not know the personnel at the hospital.