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.

 

[Tortoise]

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?

Perhaps Dr John Gibbs' (consultant) evidence to the Inquiry best answers this and sets out the sequence at that time -

Page 166 - 175

[A] And then we were -- I say it was emotional, a letter was read out from Letby by one of the senior nurses in a quite emotional tone and then we were told how much we had upset Letby by the Chief Executive and told firmly that the board had accepted the findings that there had been no evidence of any wrongdoing and that Letby was exonerated -- I don't know if he used the word "exonerated" -- but no evidence against her and that a line was being drawn under this and that was said quite firmly. I thought the Chief Executive finished by saying, "Is that clear?" as he looked round the room at each of us. I think some of my colleagues thought he said something slightly differently but they can report on that.

Q. We are interested of course in your recollection --

A. But it was clear that was the end of it. The board had accepted these reports had shown no wrongdoing and we were to apologise to Letby.

Q. You used the word "shocked" in your witness statement.

A. Yes.

Q. Particularly by reference to the fact that you hadn't reviewed at that time either the RCPCH or the Dr Hawdon report?

A. Yes.

Q. I mean, in the ordinary course of things --and I do recognise in my question that this wasn't the ordinary course of things -- but are management generally open with Consultants in relation to the content of expert reports before they discuss that content with the Consultants?

A. I am not sure because I hadn't had experience of this situation with those managers. It had been my experience as a Clinical Director some years earlier that the managers then were more consultative and for example would have probably shown us the reports and had a discussion about it?

Q. So you were told a line had to be drawn under it?

A. (Nods)

Q. Under the Letby issue, as sometimes it is characterised. But you and your colleagues wrote a letter to Mr Chambers four days later and we will just bring it up, INQ0003095. Signed by you all. You asked specifically what the board's understanding of the reason for the increased number of unexpected and unexplained deaths on the neonatal unit between June 2015 and July 2016 and "the actions that you and the board now expect us paediatricians to take". And go on to say that you want to read the RCPCH report and the Casenote Review and give an assurance that it will be kept confidential?

A. Yes.

Q. What was your thinking behind asking specifically for the board's understanding of the reason for the increase, what were you trying to achieve by asking that very direct and specific question?

A. Well, we paediatricians couldn't understand the increase. Interestingly, the board could, and we wanted to know their reasons for accepting why there had been an increase. Obviously it would help us to have read the actual reports to try and understand it.

MR DE LA POER: Thank you. My Lady, would that be a convenient moment?
LADY JUSTICE THIRLWALL: Yes, thank you very much indeed,
Mr De La Poer. 20 past 3.(3.04 pm)
(A short break)(3.20 pm)

MR DE LA POER: We had reached 30 January of 2017 and is this right, there were two issues confronting the Consultant paediatric body: on the one hand you hadn't at that time read the reports which had only been summarised to you in a particular way?

A. (Nods)

Q. But also was it your understanding at that time that Letby would be returning to the ward?

A. Yes.

Q. And how imminent was it did you have the impression that that was going to happen?

A. I wasn't sure. Within the next week or two I presumed, not that day.

Q. So I am going to come now to a WhatsApp chat which I think you have been asked to consider as part of your preparation. We can deal with it in summary. It is a discussion between you and your Consultant colleagues between 5 and 7 February in which you are effectively discussing between yourselves why it is only some of you will be permitted to view the report and others would not be able to?

A. Yes, which dates again, 5 February onwards?

Q. 5 February onwards.

A. I think that's probably referring to the Hawdon report. I think we were all given the Royal College report.

Q. Well, we know on 7 February you were in fact all given access to the RCPCH report.

A. Okay, right.

Q. Perhaps it doesn't matter terribly.

A. One or both reports only a few of us were going to see originally.

Q. Yes, and did you also at about that time get access to Dr Jane Hawdon's report?

A. Around that time, yes. I thought we had the Royal College report a day or two before the other report, but a few days apart. It didn't really make any difference.

Q. You obviously had the opportunity to consider both reports?

A. Yes.

Q. What you say? Your statement is once you got access to both, you realised that deliberate harm had not been excluded?

A. Yes.

Q. When you read them, how obvious to you was that conclusion?

A. Fairly obvious from -- I mean, deliberate harm hadn't been confirmed either. From Dr Hawdon, the expert review that four were unexplained deaths, sort of similar to what -- not necessarily four, similar to we felt these were unusual deaths, it wasn't just the number, it was the nature.

Q. Those being category 2?

A. Yes, four patients.

Q. Which she recommended for broad forensic review --

A. Yes.

Q. -- or local forensic review depending on which part of the report we are looking at?

A. Yes.

Q. Again just bookmarking an event without going to the detail, records indicate that you contacted the British Medical Association on 7 February?

A. (Nods)

Q. Why did you do that?

A. Because I realised I could be in conflict with senior managers and potentially I might be disciplined or suspended or lose my job and that's also why I contacted the MDU.

Q. What was it that you thought you might do at that time that was going to put you in conflict with the managers?

A. Go against what the managers had clearly advised; that that's the end of the discussion about Letby.

Q. So in other words that you wouldn't accept that a line had been drawn under it?

A. Absolutely, that's why we sent the letter a few days later to the Chief Executive knowing it might get us into trouble.

Q. That was the letter of 10 February 2017?

A. We sent one a few days earlier, the one at the end of January.

Q. 30 January we looked at?

A. Yes.

Q. That's where you asked specifically for the board's understanding of the explanation?

A. But even at that stage we had not drawn a line under it and we defied what we were told and we were starting to ask questions, and again on the 10th.

Q. If we bring up the 10 February letter, INQ0003117. So this letter written following --

A. Having read the reports.

Q. Exactly so. You give the dates 3 and 7 February?

A. (Nods)

Q. The substance of the letter goes on to urge a Coronial investigation?

A. Yes.

Q. Why did you think that the Coroner was the right person in these circumstances?

A. Because the Coroner is supposed to examine deaths to try and ascertain why they occurred and we thought if he had access to Dr Hawdon's report and knew of our concerns, that that would ring major alarm bells for the Coroner.

Q. So --

A. And in a very loose way -- and I might have got this wrong, I am not a legal person -- I thought going to the Coroner is not the same as going to the police, but I thought they were closely linked. If you had deaths you could not explain and that we were raising the sort of concerns we paediatricians were raising.

Q. At the end of the second paragraph: "The reports have not reassured us that all these deaths and collapses are explicable by natural causes"?

A. Yes.

Q. What isn't said in terms in this letter is: we remain suspicious of Letby.

A. Yes.

Q. Is there any particular reason why that express statement of the sort of the concern was not included in this letter?

A. Well, maybe we were being a little bit cowardly. We didn't want to ask to be sacked so we had been told this was the end of the matter and the board decided it was the end of the matter. We were clearly pushing it and without -- we didn't feel we had to explicitly say we still had the same concerns that patients had been harmed and that it may be Letby doing it because we had been told to leave it. But we felt this sort of letter implied the same thing without stating it.

page 183 - 184

Q. The same day -- we will just bring it up --28 February 2017, INQ0003187 -- the seven of you Consultants wrote a letter of apology to Letby?

A. Yes.

Q. Let's just be clear about this. You I am sure have been over the text of this many times both before it was sent and afterwards. Were you accepting when you sent that letter that you didn't think Letby had done anything wrong?

A. Sorry, can you pose that question again?

Q. Do you want to just read it and then ...(Pause)

A. Sorry, yes. We were not saying she had done no wrong here, we were just apologising for the stress that has been caused. In fact, did we say to her or not? "You", it says, yes. We were sorry for the stress we had caused all the other nurses on the unit as well. So we are apologising for the stress, we weren't apologising for the -- I think from my colleagues saying we never accused her of anything, I think we implied quite strongly what we were accusing her of. But we didn't apologise for having raised concerns that she may have harmed patients.

Q. Thank you, we can take that down. 1 March another letter to Mr Chambers, INQ0006816.

A. This in a way is emphasising the fact we have reviewed Dr Hawdon's report with Dr Subhedar and there were now eight unexplained deaths, we felt. We were pointing that out to Mr Chambers.

Q. We will just bring it up but you have got there without needing to see it. Was that the purpose of this letter, just to say: look, we have got to a particular position. It is not four, it's at least eight?

A. Yes, do we say that in this letter? I thought we had, but ...

Q. I think you will see it over the page.

A. Right.

Q. If my recollection is ... The second bulletpoint.

A. Yes. So we are saying there are eight cases altogether.

Q. Exactly so.

A. And saying this needs to be investigated...

01/10/2024 – Transcript of Week 4 Day 2 | The Thirlwall Inquiry

Transcript of Part B Evidence: Dr John Gibbs – Consultant Paediatrician

thirlwall.public-inquiry.uk

 

[Tortoise]

The execs should be thanking their lucky stars, and the consultants, that they risked their careers and defied them. She would have murdered again and again and again with impunity, and I am sure it would have been even harder to get her removed and investigated a second time with the CEO having already apologised to her. They would be doing prison time for sure, IF she was ever caught and stopped. IMO

She was expecting to be reinstated at that point in Jan 2017, police were contacted in April/May 2017, and unbelievably she still remained in employment there until her arrest in July 2018.

What happened with her grievance procedure between the board meeting in Jan 2017 and her arrest in 2018, 18 months later? I mean I know the first one was concluded in her favour, but did she not take out another one?

She attended 4 months of clinical observations with Dr Choc at Alder Hey from December 2016 to April 2017, and an Insulin Pump road show on 22nd April 2017. Dr Choc lied on the form he signed for her, saying he had worked with her on the COCH NNU until Sep 2016, when in fact she was taken off the NNU in July 2016.

INQ0100851 – Page 2 -3 of document created by Doctor U for Letby’s revalidation regarding her observation visits at Alder Hey Hospital | 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]

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

Evidence given yesterday by Dr McGuigan, employed as a neonatal and paediatric consultant at the Countess from beginning of Jan 2017, about Letby's letter -

Q. You tell us that the next event was that a statement by Letby was read out. Was that given any introduction by anybody?

A. I think it might have been written by Letby's parents, if my recollection is correct. There was some degree of introduction that there had been a grievance procedure and that this letter would summarise, from Lucy Letby's experiences, the suffering that she'd experienced over the preceding months while she'd been under investigation.

08/10/2024 – Transcript of Week 5 Day 2 | The Thirlwall Inquiry

Transcript of Part B Evidence: Dr McCormack – Consultant Obstetrician and Gynaecologist Dr McGuigan – Consultant Paediatrician Dr Jameson – Chair, Medical Staff Committee Dr Tighe – Chair, BMA Local Negotiating Committee Chair

thirlwall.public-inquiry.uk

 

[Tortoise]

I reckon the letter was a collaborative effort by Letby and her parents. JMO

 

[Tortoise]

Lucy Letby encouraged by manager to visit Alder Hey children’s hospital, inquiry hears

Countess of Chester senior nurse said placements would give Letby ‘break’ from stress, despite knowing she was under investigation over babies’ deaths

www.theguardian.com

Lucy Letby was encouraged by a senior nurse to undertake regular visits to Alder Hey children’s hospital despite her being under investigation on suspicion of murdering babies, a public inquiry has heard.

[...]

De Beger said she knew that Letby was accused of murdering babies when she encouraged the visits to Alder Hey in April 2017, but that she assumed they had been agreed by senior managers.

[...]

De Beger also told the inquiry that Letby had requested a meeting with her on the anniversary of one of the baby’s deaths when she was feeling “particularly distressed”. She said Letby told her: “I’m distressed but how much more distressed would the parents be at the loss of their baby.”

 

[ColourPurple]

De Beger also told the inquiry that Letby had requested a meeting with her on the anniversary of one of the baby’s deaths when she was feeling “particularly distressed”. She said Letby told her: “I’m distressed but how much more distressed would the parents be at the loss of their baby.”

Sounds like an excuse for her to be able to discuss and relive the murder with somebody. One of her trips with Doc Choc was also on the anniversary of one of the murders.

 

[ColourPurple]

I'm not at all convinced of that, tbh. We can't say either way but, on balance, I don't think they were.

If one of her driving motivations for murdering patients was to get his attention - as has been suggested - then why would there be that need if she'd already got him?

Ignoring the trips away, the late night chats with plenty of redactions in the transcript that suggest a full blown affair and the fact she eventually admitted in court he was her boyfriend and had apparently contacted his wife too…she hadn’t already “got” him . Not exclusively anyway . He had a wife and kids he went home to and a job where he and LLs shifts didn’t always coincide . The time she got to spend with him was limited but could be increased if there were emergencies on the NNU that he had to respond to …so that’s what she did…created those emergencies to get him on the ward to spend more time with him. Similar to fellow nurse serial killer Kristen Gilbert

With the added bonus that she got to impress him with her calmness annd then they would trauma bond during the emergency and then she’d be able to relive it all when they were talked and texted about it later. And the longer the emergency lasted the more time she got to spend with him. The more tragic it was the more “support” they’d have to give each other.

By the end she was timing the attacks for when he was on shift and even turned away another doctor when they responded to an emergency beep and specifically asked for Doc Choc to come instead. And after one successful resuscitation he popped for a tea break with a female doctor and before the kettle had even boiled, LL had attacked the baby again and he was bleeped to come back!

I don’t think getting attention from him or the other doctors was the only reason she attacked and murdered babies. I think she saw the babies as mere props in the “Lucy Letby Super Nurse” docu-soap storyline and … attacked for various reasons … spite, jealousy, boredom, and because she enjoyed outwitting the doctors, enjoyed causing pain physical and emotional, and enjoyed killing them and then the excitement of preparing memory boxes, bathing and dressing the babies for the last time and watching the parents grieving first hand.

 

[katydid23]

Ignoring the trips away, the late night chats with plenty of redactions in the transcript that suggest a full blown affair and the fact she eventually admitted in court he was her boyfriend and had apparently contacted his wife too…she hadn’t already “got” him . Not exclusively anyway . He had a wife and kids he went home to and a job where he and LLs shifts didn’t always coincide . The time she got to spend with him was limited but could be increased if there were emergencies on the NNU that he had to respond to …so that’s what she did…created those emergencies to get him on the ward to spend more time with him. Similar to fellow nurse serial killer Kristen Gilbert

YES. She was on a quest, he was not fully hers. But besides that, she needed to pull him in by showing off to him, about how organised and dedicated and competent she was, especially during crash cart time.

With the added bonus that she got to impress him with her calmness annd then they would trauma bond during the emergency and then she’d be able to relive it all when they were talked and texted about it later. And the longer the emergency lasted the more time she got to spend with him. The more tragic it was the more “support” they’d have to give each other.

Sooooo true. She was in the limelight when the emergencies were happening. She could shine and it bonded them further to be able to talk about it all on FB for hours. AND the cunning manipulative nurse could milk the doctor for important behind the scenes information about what the other doctors were thinking about her.

By the end she was timing the attacks for when he was on shift and even turned away another doctor when they responded to an emergency beep and specifically asked for Doc Choc to come instead. And after one successful resuscitation he popped for a tea break with a female doctor and before the kettle had even boiled, LL had attacked the baby again and he was bleeped to come back!

THAT was so revealing. She literally attacked a baby because she saw her Doc Choc walking away to have tea with a female Doc.

I don’t think getting attention from him or the other doctors was the only reason she attacked and murdered babies. I think she saw the babies as mere props in the “Lucy Letby Super Nurse” docu-soap storyline and … attacked for various reasons … spite, jealousy, boredom, and because she enjoyed outwitting the doctors, enjoyed causing pain physical and emotional, and enjoyed killing them and then the excitement of preparing memory boxes, bathing and dressing the babies for the last time and watching the parents grieving first hand.

THAT^^^ is such a perfect description. She attacked innocent babies and their parents for a wide variety of motives. Basically she enjoyed it.

 

[Baby baby Jane]

YES. She was on a quest, he was not fully hers. But besides that, she needed to pull him in by showing off to him, about how organised and dedicated and competent she was, especially during crash cart time.

Sooooo true. She was in the limelight when the emergencies were happening. She could shine and it bonded them further to be able to talk about it all on FB for hours. AND the cunning manipulative nurse could milk the doctor for important behind the scenes information about what the other doctors were thinking about her.

THAT was so revealing. She literally attacked a baby because she saw her Doc Choc walking away to have tea with a female Doc.

THAT^^^ is such a perfect description. She attacked innocent babies and their parents for a wide variety of motives. Basically she enjoyed it.

I think she also had contempt for the babies’ mothers … she didn’t want them on her ward, nor share the grief limelight with them. I think her crimes were also about mothers/motherhood and punishing mums & resenting them. (Recalling my being the mum on SCIBU, nurses were very deferential to new mums with special babies.) IMO.

 

[Highlandspring]

Ignoring the trips away, the late night chats with plenty of redactions in the transcript that suggest a full blown affair and the fact she eventually admitted in court he was her boyfriend and had apparently contacted his wife too…she hadn’t already “got” him . Not exclusively anyway . He had a wife and kids he went home to and a job where he and LLs shifts didn’t always coincide . The time she got to spend with him was limited but could be increased if there were emergencies on the NNU that he had to respond to …so that’s what she did…created those emergencies to get him on the ward to spend more time with him. Similar to fellow nurse serial killer Kristen Gilbert

With the added bonus that she got to impress him with her calmness annd then they would trauma bond during the emergency and then she’d be able to relive it all when they were talked and texted about it later. And the longer the emergency lasted the more time she got to spend with him. The more tragic it was the more “support” they’d have to give each other.

By the end she was timing the attacks for when he was on shift and even turned away another doctor when they responded to an emergency beep and specifically asked for Doc Choc to come instead. And after one successful resuscitation he popped for a tea break with a female doctor and before the kettle had even boiled, LL had attacked the baby again and he was bleeped to come back!

I don’t think getting attention from him or the other doctors was the only reason she attacked and murdered babies. I think she saw the babies as mere props in the “Lucy Letby Super Nurse” docu-soap storyline and … attacked for various reasons … spite, jealousy, boredom, and because she enjoyed outwitting the doctors, enjoyed causing pain physical and emotional, and enjoyed killing them and then the excitement of preparing memory boxes, bathing and dressing the babies for the last time and watching the parents grieving first hand.

I agree there were various motives including all the above, gambling with the babies' lives was another - she talked about fate and chances, and cheerfully texted her parents to ask for her dad to put a bet on the Grand National on the day Baby L got insulin poisonings (9 April i think) and texted people that she'd won a few quid in the same message about the collapse iirc. And like others I've been deleted for talkimg motive during the trial, understandably.

Like you and many of us, I'm sure the overriding motive was destroying happiness and the status quo. Replacing it with chaos and devastation for parents, wider family, NHS staff. Like a bomb. Her 'bang'.

The calculation and psychopathy of her using the babies as a means to an end makes it seem even worse, though I know that it couldn't actually be worse.

Sorry I'm sure I'm repeating others and myself again but helps to get it out doesn't it.

 

[Highlandspring]

I think she also had contempt for the babies’ mothers … she didn’t want them on her ward, nor share the grief limelight with them. I think her crimes were also about mothers/motherhood and punishing mums & resenting them. (Recalling my being the mum on SCIBU, nurses were very deferential to new mums with special babies.) IMO.

Good point, I bet that was a big factor in it, she clearly felt superior to most of the staff... New mums were one group she couldn't easily boss around or lord it over, although she did with poor Baby E's mother at least didn't she. Just so horrendous.

I think she also had contempt for the babies’ mothers … she didn’t want them on her ward, nor share the grief limelight with them. I think her crimes were also about mothers/motherhood and punishing mums & resenting them. (Recalling my being the mum on SCIBU, nurses were very deferential to new mums with special Good point, I'm sure you're right. They're

 

[Highlandspring]

I agree there were various motives including all the above, gambling with the babies' lives was another - she talked about fate and chances, and cheerfully texted her parents to ask for her dad to put a bet on the Grand National on the day Baby L got insulin poisonings (9 April i think) and texted people that she'd won a few quid in the same message about the collapse iirc. And like others I've been deleted for talkimg motive during the trial, understandably.

Like you and many of us, I'm sure the overriding motive was destroying happiness and the status quo. Replacing it with chaos and devastation for parents, wider family, NHS staff. Like a bomb. Her 'bang'.

The calculation and psychopathy of her using the babies as a means to an end makes it seem even worse, though I know that it couldn't actually be worse.

Sorry I'm sure I'm repeating others and myself again but helps to get it out doesn't it.

Actually both twins collapsed on the 9th, L and M.

 

[Tortoise]

INQ0101342 – Text messages between Kathryn de Beger and Letby, dated 16/04/2017 and 27/04/2017 | 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]

INQ0101342 – Text messages between Kathryn de Beger and Letby, dated 16/04/2017 and 27/04/2017 | 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

Ms de Beger also emailed Letby while she was suspended to tell her she should feel reassured that hospital executives supported her wish to return to the neonatal unit.

Letby replied: "I feel as though this must be my fault and maybe I’ve done something wrong to the babies - and blame myself - do you think that’s normal?"

Ms de Beger said she had regular occupational health sessions with Letby, and on one occasion the nurse brought her parents along.

There was a family row during the meeting, which centred around how Letby should deal with the process of being removed from duty.

The inquiry, also heard how chief executive Tony Chambers had wanted to "draw a line under the 'Lucy issue'" at the occupational health meeting.

It had been said that two independent reviews had found no evidence of deliberate harm, and a grievance that Letby lodged over her removal had been upheld.

Lucy Letby 'distressed' at 'murderer' remarks, inquiry hears

An inquiry into Lucy Letby’s crimes is told the nurse was "distressed" by doctors' comments.

www.bbc.com

 

[katydid23]

Lucy Letby 'distressed' at 'murderer' remarks, inquiry hears

An inquiry into Lucy Letby’s crimes is told the nurse was "distressed" by doctors' comments.

www.bbc.com

Dr Sean Tighe, a consultant anaesthetist, was asked to attend as a witness in his role as union representative for the doctors at the meeting.

He and the others present heard Letby state that her "life was turned upside down and subsequently put on hold" when she found out she was being removed from the unit in July 2016.

She added: "There has been a huge element of dishonesty throughout this process and I want to ensure that you all hear my perspective and are aware of the impact your actions have had on me.

"I appreciate that we all have a right to raise concerns and that the protection of our vulnerable patient group, is, of course, of paramount importance.

"However, I find it extremely unprofessional and hurtful to have been made aware of such unsubstantiated insensitive comments, as listed below, often via 'word of mouth'.

Dr Tighe told the inquiry: "We had been told that the meeting was to explore the reports, the contents of the reports, and to explore the possibility of Ms Letby returning to work, not to hear a 20-minute melodramatic dissertation from Ms Letby herself."

He said the consultants responded by "completely denying" they had made any derogatory remarks, which Mr Chambers demanded they apologise for.