UK - Lucy Letby - Post-Conviction Statutory Inquiry

[Tortoise]

Letby's letter to the consultants read out on her behalf by Karen Rees, at the meeting when they were told to apologise to her. Jan 2017.

INQ0012080 – Pages 1 – 2 of statement from Letby regarding her removal from the neonatal unit and grievance raised, dated 09/01/2017 | 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

 

[katydid23]

Letby's letter to the consultants read out on her behalf by Karen Rees, at the meeting when they were told to apologise to her. Jan 2017.

INQ0012080 – Pages 1 – 2 of statement from Letby regarding her removal from the neonatal unit and grievance raised, dated 09/01/2017 | 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

Final 2 paragraphs of Lucy's letter, where she announces her upcoming return to the unit:

'"After working with you all in a professional and supportive manner during difficult and challenging times I have been hurt and disappointed that those of you who did not openly raise concerns felt unable to be more supportive of me in this situation.

The detrimental effect this has had on me, my family, and potentially my future is immense. Many months of worry, distress, secrecy and uncertainty has had a significant impact on my physical health, general wellbeing and self-confidence. I am not the person I was before this began. It is only now that there is some light at the end of the tunnel that I feel as though I can start to try to become the personI was before.

A lot of people would leave / move on/ have a fresh start and I know that is the feeling which has been conveyed to me by some of you "the longer she is away from the unit, the more likely she will be to leave", however, I am very passionate about and dedicated to Chester -it is where I undertook my nurse training and the unit helped me to grow from a student to a newly qualified nurse and beyond. Although this has been very traumatic, my strong desire to remain in Chester and within CoCH remains, and I am hopeful that we can find a professional way forward to enable my return to where I feel I belong."

 

[sunspun]

Final 2 paragraphs of Lucy's letter, where she announces her upcoming return to the unit:

'"After working with you all in a professional and supportive manner during difficult and challenging times I have been hurt and disappointed that those of you who did not openly raise concerns felt unable to be more supportive of me in this situation.

The detrimental effect this has had on me, my family, and potentially my future is immense. Many months of worry, distress, secrecy and uncertainty has had a significant impact on my physical health, general wellbeing and self-confidence. I am not the person I was before this began. It is only now that there is some light at the end of the tunnel that I feel as though I can start to try to become the personI was before.

A lot of people would leave / move on/ have a fresh start and I know that is the feeling which has been conveyed to me by some of you "the longer she is away from the unit, the more likely she will be to leave", however, I am very passionate about and dedicated to Chester -it is where I undertook my nurse training and the unit helped me to grow from a student to a newly qualified nurse and beyond. Although this has been very traumatic, my strong desire to remain in Chester and within CoCH remains, and I am hopeful that we can find a professional way forward to enable my return to where I feel I belong."

So forgive my oversimplified attempt at a summary here, but it seems she was under a veil of suspicion at some earlier point, which somehow eventually lifted to the point where they were apologizing to HER, and then there was a start at going back to a "normal" for a bit, which didn't last, because she was again somehow not only suspected, but officially, formally investigated, and she ended up in custody and then at trial and then convicted and imprisoned, which is where it is now (actually, on appeal, I guess, now).

Which is about the point that I personally started reading about this case (very late, i.e.), hence my oversimplification of events. But that leaves a gap in my understanding of it all, because how did she come to that point where they apologized to her, only to end up convicted in the end? Their suspicions were correct early on, but why were they dropped, only to return full force later? Or was that not a true apology, maybe they were just trying to make her drop her guard or make her think she was in the clear for some reason? Or was the investigation of her still going on, even while the staff were told something different? Maybe LE still suspected her and were continuing to investigate, even while her coworkers were told she was cleared and deserved an apology?

 

[katydid23]

So forgive my oversimplified attempt at a summary here, but it seems she was under a veil of suspicion at some earlier point, which somehow eventually lifted to the point where they were apologizing to HER, and then there was a start at going back to a "normal" for a bit, which didn't last, because she was again somehow not only suspected, but officially, formally investigated, and she ended up in custody and then at trial and then convicted and imprisoned, which is where it is now (actually, on appeal, I guess, now).

Which is about the point that I personally started reading about this case (very late, i.e.), hence my oversimplification of events. But that leaves a gap in my understanding of it all, because how did she come to that point where they apologized to her, only to end up convicted in the end? Their suspicions were correct early on, but why were they dropped, only to return full force later? Or was that not a true apology, maybe they were just trying to make her drop her guard or make her think she was in the clear for some reason? Or was the investigation of her still going on, even while the staff were told something different? Maybe LE still suspected her and were continuing to investigate, even while her coworkers were told she was cleared and deserved an apology?

Here is MY interpretation of your valid questions. It might be a long summary perhaps, as it is a complex situation. But in a large nutshell, in my opinion, it went like this----[timeline from the Independent added to my thoughts]

Timeline of killer nurse Lucy Letby’s attacks and investigation

Lucy Letby has now been convicted of the murder of seven babies, and the attempted murder of seven others

www.the-independent.com

8 June 2015 - MURDER: Child A =Child A is born six weeks premature and given to Letby on her night shift. He “deteriorates rapidly” and dies within 90 minutes of Letby coming on duty.
8-11 June - ATTEMPTED MURDER: Child A’s twin sister, Child B, is injected with air by Letby - and survives after being resuscitated.
14 Jun - MURDER: Child C, born seven weeks premature, dies as a result of air being injected into his stomach. Letby is seen standing over his monitor as his alarm sounds.
22 June - MURDER : Child D, a full-term baby girl, dies 36 hours after her birth at the Countess of Chester Hospital. Letby had injected air into the child’s bloodstream.

End of June/July: A meeting takes place between neonatal lead consultant Dr Stephen Brearey and director of nursing Alison Kelly, along with other bosses, to discuss an informal review undertaken by Dr Brearey of Child D’s death. His findings reveal an “association” with nurse Lucy Letby and her presence at the recent collapses.

ME: There were 4 serious incidents, 3 deaths and one near death, within a 14 day span, in June of 2015.
Initially the doctors were concerned there was a possible infection or contagious superbug spreading through the clinic.

So when they noticed the 'association' with Nurse L and these first 4 incidents, they did not assume it was anything malicious. They were wondering if she was contagious or maybe clumsy , incompetent, or very unlucky, or something along those lines.


4 August - MURDER: Child E dies after air is injected into his bloodstream. The baby’s mother interrupts Letby in her attack, but doesn’t realise it.
5 August - ATTEMPTED MURDER : Blood sugar levels of a prematurely born baby boy, Child F, fall dangerously low, and a blood sample is sent for tests at the Royal Liverpool Hospital. The baby survives.
7 September - ATTEMPTED MURDER: Baby G left severely disabled by Letby, who tries to murder her twice, the second instance on 21 September, through air via her nasogastic tube.
23 October - MURDER: Child I, a prematurely born girl, dies on the unit. Concerns are raised again by some consultants in an email.

8 February 2016: A “thematic” review by an independent neonatologist based at Liverpool Women’s Hospital takes place. The review, requested by Dr Brearey, does not find a reason for the increased number of deaths and collapses, but concerns remain over Letby as the report is forwarded to nursing director Ms Kelly and medical director Ian Harvey.

ME: So at this point, the collapses and deaths continued, but at a slower pace, and Nurse L tries harder to camouflage her connection to the victims.
However the Consultants and Senior Doctors have even stronger suspicions about Nurse Letby. And they wrote to the administrators to repeat their serious concerns.
But Letby had begun to cover her tracks in cunning ways. She was harming babies not under her direct care and she was falsifying some of her medical logs, so during the review process it wouldn't look like she was connected to any of the collapses.
Also the initial medical reviews did not find the causes or the suspicious connections. Nurse L was changing up the methods of attack, so it was hard to see the pattern.

17 February - ATTEMPTED MURDER: Child K taken to neo-natal unit’s intensive care room after being born premature. Letby seen dislodging breathing tube from baby. Baby taken to hospital and dies three days later.
9 April - ATTEMPTED MURDER x 2: Another youngster, Child L, suffers a hypoglycaemic episode in which his blood sugar level plunges. At around the same time, his twin brother, Child M, unexpectedly collapses and requires full resuscitation before he recovers. A blood sample from Child L is sent for tests at the Royal Liverpool Hospital.
3 June - ATTEMPTED MURDER: Child N, a newborn boy with haemophilia, attacked by Letby who thrusts nasogastic tube into his throat.
24 June - MURDER x 2: Child P, one of a set of triplet boys, collapses and dies a day after the death on the unit of his newborn brother, Child O.

Dr Brearey phones the duty executive on call, Karen Rees, a senior nurse in the urgent care division, to say that he and his consultant colleagues do not want Letby to work her next scheduled shift on 25 June, but she rejects the plea.

25 June - ATTEMPTED MURDER: Ninety minutes into Letby’s day shift, Child Q, a prematurely born boy, needs breathing support after his blood oxygen levels and heart rate plummet. He goes on to make a full recovery.


ME: There were 7 serious incidents in a 4 month time span. But the methods of attack were all different and more spread out than previously EXCEPT FOR THE ATTACKS ON JUNE 24TH.

Those attacks on 2 of the triplets, Child O and Child P were so obviously done by Nurse Letby that the Doctors just had to STOP her at this point.

She had been away on a 17 day vacation until June 24th. YES, on the very day she returned from vacation, 2 of the newborn triplets were attacked and killed!

29 June: Consultants meet to discuss recent “inexplicable” events and then urge hospital bosses to remove Letby from the unit as a safety measure.
30 June: Letby works her last nursing shift on the neonatal unit.

ME:At this point, the Consultants were able to force Letby off of the patient floor. However, the strong Nursing Union prevented her from being suspended or fired.

7 July: Hospital bosses reduce the neonatal unit service by cutting cot spaces and increasing the gestational age limit for admission from a minimum of 27 to 32 weeks.
15 July: An email is sent to all nursing staff informing them that they will each undergo a period of clinical supervision – after medical director Mr Harvey asked the Royal College of Paediatrics and Child Health (RCPCH) to conduct a review of the unit’s service. The email states: “Lucy has agreed to undergo this supervision first on Monday 18th July.”
19 July: Letby starts an administrative post in the hospital’s Patient Experience Team.


ME: So Letby is transferred to the Patient Safety Team--- And she continues to be on the Hospital's payroll and comes to the clinic every day.


7 September: Letby registers a formal grievance procedure against her employer. Around this time, the Royal College of Nursing union informs her by letter about allegations surrounding her involvement in a number of deaths.

November 2016: The RCPCH says it found no obvious factors linking a total of eight deaths in the neonatal unit in 2015 and five deaths up to July 2016. However, it did uncover significant gaps in medical and nursing rotas, and insufficient staffing for the provision of longer-term high dependency and some intensive care.

ME: So it was after the RCPCH did it's review, and found no obvious links between the 8 deaths, that the Nursing Administration in the clinic decided to bring Nurse Letby back into the unit and to her old job...And so thy asked all of the staff to write her an apology before she returned to work...


18 May 2017: Cheshire Police announce they have launched an investigation following “a greater number of baby deaths and collapses” at the hospital between June 2015 and June 2016. The probe will focus on eight deaths and will also review seven further deaths and six non-fatal collapses.

3 July 2018: Letby is arrested at her home in Westbourne Road, Chester, at 6am, and officers search the three-bedroom property. Searches also take place at her parents’ home in Hereford and her place of work in the hospital’s Risk and Patient Safety Office. Police say the investigation has widened to 17 deaths and 15 non-fatal collapses between March 2015 and July 2016.


ME: so the OP Question was : how did she come to that point where they apologized to her, only to end up convicted in the end?

In a nutshell, The Doctors tried to get her off the floor and to be investigated for harming the children. But both the Administration and Nurses Union blocked those attempts, tried to have her return to nursing and demanded written apologies from the staff.

But to be fair, Nurse Letby was very cunning and learned to falsify records, lie, and change up the methods off attack, so it was hard for the reviewers to see what she had done.

 

[sunspun]

Here is MY interpretation of your valid questions. It might be a long summary perhaps, as it is a complex situation. But in a large nutshell, in my opinion, it went like this----[timeline from the Independent added to my thoughts]

Timeline of killer nurse Lucy Letby’s attacks and investigation

Lucy Letby has now been convicted of the murder of seven babies, and the attempted murder of seven others

www.the-independent.com

8 June 2015 - MURDER: Child A =Child A is born six weeks premature and given to Letby on her night shift. He “deteriorates rapidly” and dies within 90 minutes of Letby coming on duty.
8-11 June - ATTEMPTED MURDER: Child A’s twin sister, Child B, is injected with air by Letby - and survives after being resuscitated.
14 Jun - MURDER: Child C, born seven weeks premature, dies as a result of air being injected into his stomach. Letby is seen standing over his monitor as his alarm sounds.
22 June - MURDER : Child D, a full-term baby girl, dies 36 hours after her birth at the Countess of Chester Hospital. Letby had injected air into the child’s bloodstream.

End of June/July: A meeting takes place between neonatal lead consultant Dr Stephen Brearey and director of nursing Alison Kelly, along with other bosses, to discuss an informal review undertaken by Dr Brearey of Child D’s death. His findings reveal an “association” with nurse Lucy Letby and her presence at the recent collapses.

ME: There were 4 serious incidents, 3 deaths and one near death, within a 14 day span, in June of 2015.
Initially the doctors were concerned there was a possible infection or contagious superbug spreading through the clinic.

So when they noticed the 'association' with Nurse L and these first 4 incidents, they did not assume it was anything malicious. They were wondering if she was contagious or maybe clumsy , incompetent, or very unlucky, or something along those lines.


4 August - MURDER: Child E dies after air is injected into his bloodstream. The baby’s mother interrupts Letby in her attack, but doesn’t realise it.
5 August - ATTEMPTED MURDER : Blood sugar levels of a prematurely born baby boy, Child F, fall dangerously low, and a blood sample is sent for tests at the Royal Liverpool Hospital. The baby survives.
7 September - ATTEMPTED MURDER: Baby G left severely disabled by Letby, who tries to murder her twice, the second instance on 21 September, through air via her nasogastic tube.
23 October - MURDER: Child I, a prematurely born girl, dies on the unit. Concerns are raised again by some consultants in an email.

8 February 2016: A “thematic” review by an independent neonatologist based at Liverpool Women’s Hospital takes place. The review, requested by Dr Brearey, does not find a reason for the increased number of deaths and collapses, but concerns remain over Letby as the report is forwarded to nursing director Ms Kelly and medical director Ian Harvey.

ME: So at this point, the collapses and deaths continued, but at a slower pace, and Nurse L tries harder to camouflage her connection to the victims.
However the Consultants and Senior Doctors have even stronger suspicions about Nurse Letby. And they wrote to the administrators to repeat their serious concerns.
But Letby had begun to cover her tracks in cunning ways. She was harming babies not under her direct care and she was falsifying some of her medical logs, so during the review process it wouldn't look like she was connected to any of the collapses.
Also the initial medical reviews did not find the causes or the suspicious connections. Nurse L was changing up the methods of attack, so it was hard to see the pattern.

17 February - ATTEMPTED MURDER: Child K taken to neo-natal unit’s intensive care room after being born premature. Letby seen dislodging breathing tube from baby. Baby taken to hospital and dies three days later.
9 April - ATTEMPTED MURDER x 2: Another youngster, Child L, suffers a hypoglycaemic episode in which his blood sugar level plunges. At around the same time, his twin brother, Child M, unexpectedly collapses and requires full resuscitation before he recovers. A blood sample from Child L is sent for tests at the Royal Liverpool Hospital.
3 June - ATTEMPTED MURDER: Child N, a newborn boy with haemophilia, attacked by Letby who thrusts nasogastic tube into his throat.
24 June - MURDER x 2: Child P, one of a set of triplet boys, collapses and dies a day after the death on the unit of his newborn brother, Child O.

Dr Brearey phones the duty executive on call, Karen Rees, a senior nurse in the urgent care division, to say that he and his consultant colleagues do not want Letby to work her next scheduled shift on 25 June, but she rejects the plea.

25 June - ATTEMPTED MURDER: Ninety minutes into Letby’s day shift, Child Q, a prematurely born boy, needs breathing support after his blood oxygen levels and heart rate plummet. He goes on to make a full recovery.


ME: There were 7 serious incidents in a 4 month time span. But the methods of attack were all different and more spread out than previously EXCEPT FOR THE ATTACKS ON JUNE 24TH.

Those attacks on 2 of the triplets, Child O and Child P were so obviously done by Nurse Letby that the Doctors just had to STOP her at this point.

She had been away on a 17 day vacation until June 24th. YES, on the very day she returned from vacation, 2 of the newborn triplets were attacked and killed!

29 June: Consultants meet to discuss recent “inexplicable” events and then urge hospital bosses to remove Letby from the unit as a safety measure.
30 June: Letby works her last nursing shift on the neonatal unit.

ME:At this point, the Consultants were able to force Letby off of the patient floor. However, the strong Nursing Union prevented her from being suspended or fired.

7 July: Hospital bosses reduce the neonatal unit service by cutting cot spaces and increasing the gestational age limit for admission from a minimum of 27 to 32 weeks.
15 July: An email is sent to all nursing staff informing them that they will each undergo a period of clinical supervision – after medical director Mr Harvey asked the Royal College of Paediatrics and Child Health (RCPCH) to conduct a review of the unit’s service. The email states: “Lucy has agreed to undergo this supervision first on Monday 18th July.”
19 July: Letby starts an administrative post in the hospital’s Patient Experience Team.


ME: So Letby is transferred to the Patient Safety Team--- And she continues to be on the Hospital's payroll and comes to the clinic every day.


7 September: Letby registers a formal grievance procedure against her employer. Around this time, the Royal College of Nursing union informs her by letter about allegations surrounding her involvement in a number of deaths.

November 2016: The RCPCH says it found no obvious factors linking a total of eight deaths in the neonatal unit in 2015 and five deaths up to July 2016. However, it did uncover significant gaps in medical and nursing rotas, and insufficient staffing for the provision of longer-term high dependency and some intensive care.

ME: So it was after the RCPCH did it's review, and found no obvious links between the 8 deaths, that the Nursing Administration in the clinic decided to bring Nurse Letby back into the unit and to her old job...And so thy asked all of the staff to write her an apology before she returned to work...


18 May 2017: Cheshire Police announce they have launched an investigation following “a greater number of baby deaths and collapses” at the hospital between June 2015 and June 2016. The probe will focus on eight deaths and will also review seven further deaths and six non-fatal collapses.

3 July 2018: Letby is arrested at her home in Westbourne Road, Chester, at 6am, and officers search the three-bedroom property. Searches also take place at her parents’ home in Hereford and her place of work in the hospital’s Risk and Patient Safety Office. Police say the investigation has widened to 17 deaths and 15 non-fatal collapses between March 2015 and July 2016.


ME: so the OP Question was : how did she come to that point where they apologized to her, only to end up convicted in the end?

In a nutshell, The Doctors tried to get her off the floor and to be investigated for harming the children. But both the Administration and Nurses Union blocked those attempts, tried to have her return to nursing and demanded written apologies from the staff.

But to be fair, Nurse Letby was very cunning and learned to falsify records, lie, and change up the methods off attack, so it was hard for the reviewers to see what she had done.

Thank you, very good job explaining! That clarifies that for me! I can't see her as anything but evil. Do you think she lay awake at night reliving the moments at work when she had what she must have felt like was godlike power, and coming up with what she would do next to have that feeling again?? How warped must a mind be to absolutely relish the chaos and destruction, the sorrow and agony that she herself had set in motion, and revel in the fact that only she knew the cause of it all? The more grief and disruption she caused, the more she loved it and wanted more of it.

IMO, that's why she would look the victim families up on FB, to squeeze out even more of whatever it was she was getting out of this. It wasn't enough to see the pain and deaths of the little babies, or the sorrow and shock of the families, or the chaos in the ward or the stress and fear that she'd created there, so she went home and tried to eke out what more she could by reading the parents' announcements of the sad news they brought home from the hospital, and all the condolences and expressions of shock and sympathy from their loved ones.

IMO, it was all a power trip to her; she found she had the ability to inflict pain, to snuff out lives, to create fear and shock and stress and flurries of urgent activity and much callings of meetings and reviews of protocol and upheavals of schedules etc. etc. etc., and it was all because of HER HER HER - she did this, all by herself! And for some reason, that thrilled her and she had to have more of it, like a drug. There has to be something not right in her brain. This seems so contradictory to human nature.

But then again, I see a lot in common with those firefighters who secretly start fires. And I know there have been cases where someone actually was killed when they did that, but that's not their goal in starting the fire, I don't think. I think they too like the power they feel when they see all the activity for something they started, or in some cases, I think they just want to fight a fire, and there hasn't been one for awhile. But LL's lethality and absolute disregard for human life (and especially such tiny, vulnerable human lives) is what makes her crimes so different. It seems like people in her past would've noticed remarkable lack of empathy or compassion, but as I've read, they haven't. It really is like a terrifying horror story that some depraved mind thought up.