UK - Lucy Letby - Post-Conviction Statutory Inquiry, 21 August 2023

[Parker Knoll]

Delighted to see that YET again Davis neither knows the law or his own case.

 

[marynnu]

D

 

[marynnu]

 

[dm799]

 

[Dotta]

https://twitter.com/x/status/2037493249275785477

 

[Dotta]

https://twitter.com/x/status/2037791306911519168

 

[Ruthbullock]

The Thirlwall Inquiry is at the stage of being proofread for publication- this will take some time, but conclusions have obviously been reached and it has been wrapped up, aside from ensuring any remaining evidence referred to in the report has been uploaded.
Once released do we think this will be considered by the CCRC, or seen as a separate entity whose paths don’t need to cross?

One other question to you all- whilst the CCRC often takes many months/years to fully assess an application- are there any known scenarios where it has been resolved and dismissed quickly?

 

[JosieJo]

I can't see how the CCRC can consider it

 

[Dotta]

https://twitter.com/x/status/2038923096342557008

 

[Ruthbullock]

https://twitter.com/x/status/2038923096342557008

The headline doesn’t read the same if they had focused on this quote out of the article they printed

“Having mostly agreed with Dr Evans's conclusions, Bohin was called upon by the prosecution during the trial,”

Dr Bohin doesn’t agree with all the conclusions of the international panel, or all of Dr Evans opinions.

The headline could also have read
Expert Witness: This is what prosecutors of Letby got so wrong. It’s not an investigative piece of neutral reporting, it’s another article that is pushing its own biased narrative. Most of the press articles are the same- attempting to push public opinion one way or the other, rather than being fully informative pieces of journalism.

 

[rvlvr]

Not only is another sad attempt by Liz Hull to shore up the case (and her podcast’s legacy) but I don’t know why people are getting away with posting stuff that’s completely unrelated to the inquiry? This is a thread about Thirlwall, is it not?

 

[Ruthbullock]

“just before Letby was due to start her shift on 27 June 2016, she was called and told not to come into work. She was then moved into an administrative role.”

https://news.sky.com/story/how-the-police-caught-lucy-letby-12933640#:~:text=%22They%20mentioned%20that%20a%20member,moved%2C%20to%20shift%20the%20blame.

Yet in December they are still having meetings to keep the unit downgraded and we have parents still believing their children were harmed, but being dismissed by Hummingbird as being out of the timeline for investigation.

INQ0106992 – Page 9 Extract of Minutes and Action Points from the North Regional Quality Surveillance Group Meeting, dated 02/12/2016 | 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

The telegraph article discussing parents who complained but weren’t considered is behind a paywall. Archived links are available, but also can’t be shared on here- sorry

And it has since never been upgraded, despite hints in the meeting minutes shared above by Thirlwall from 3 months after Letby had been removed from the unit, that it may be upgraded again following the report due early 2017. In fact many, many years later it has still not been upgraded, even with a new purpose built building. That must reflect more widely on the care provided than just a single person.

 

[Ruthbullock]

DBM

 

[Sillybilly]

Hey folks,

This thread is about the inquiry, (so not about everything Letby related).

Please stay on topic. Thanks !!

 

[Ruthbullock]

It was never a skeleton staff.

According to the hospital itself and the Thirlwall documents it was. They were understaffed throughout the time period.

Firstly, the review is explicit that the neonatal service was not meeting required professional standards. It directly asks whether the service was compliant and answers: “Is the service provision compliant with current professional standards? No.” (p10/33). The unit’s own self-assessment recorded it as “non-compliant on nurse and medical staffing levels, environment and accommodation for parents, support from the community neonatal team and postnatal follow up.” (p10/33).

Secondly, medical staffing was found to be inadequate across multiple rotas. The review states “A Tier 2 rota… with at least 8 staff (not compliant)” and “A Tier 1 rota… with at least 8 staff (not compliant)” (p10/33). This indicates that the unit did not have the level of medical cover required for the complexity of care it was providing.

Thirdly, the review records that the service was “non-compliant on nurse and medical staffing levels” (p10/33),


And the report was excluded from the trial.

https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-evidence/INQ0009618_8%2C9%2C10.pdf

They were aware of the deficiency in nursing staff in 2015 and were attempting to argue for increased staffing

INQ0003829 – Business Case for Nurse Staffing in the Paediatrics Neonatal Unit, dated December 2015 | 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

There are numerous other documents, including numerous internal meetings, on Thirlwall about understaffing, but it would take days to find and share them all.

 

[marynnu]

According to the hospital itself and the Thirlwall documents it was. They were understaffed throughout the time period.

Firstly, the review is explicit that the neonatal service was not meeting required professional standards. It directly asks whether the service was compliant and answers: “Is the service provision compliant with current professional standards? No.” (p10/33). The unit’s own self-assessment recorded it as “non-compliant on nurse and medical staffing levels, environment and accommodation for parents, support from the community neonatal team and postnatal follow up.” (p10/33).

Secondly, medical staffing was found to be inadequate across multiple rotas. The review states “A Tier 2 rota… with at least 8 staff (not compliant)” and “A Tier 1 rota… with at least 8 staff (not compliant)” (p10/33). This indicates that the unit did not have the level of medical cover required for the complexity of care it was providing.

Thirdly, the review records that the service was “non-compliant on nurse and medical staffing levels” (p10/33),


And the report was excluded from the trial.

https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-evidence/INQ0009618_8%2C9%2C10.pdf

They were aware of the deficiency in nursing staff in 2015 and were attempting to argue for increased staffing

INQ0003829 – Business Case for Nurse Staffing in the Paediatrics Neonatal Unit, dated December 2015 | 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

There are numerous other documents, including numerous internal meetings, on Thirlwall about understaffing, but it would take days to find and share them all.

of course it was understaffed. Where isn't? Means absolutely nothing.

 

[JosieJo]

of course it was understaffed. Where isn't? Means absolutely nothing.

Agree ...almost every hospital in the country

 

[Ruthbullock]

The full investigation report into Letbys grievance has been uploaded. I have shared some of it below, discussing going to the police, but there is lots more to digest. Which babies initial collapse happened whilst Letby was hanging up her coat after arriving on shift? SB and RJ were not at the point of wanting to consider a referral to the police themselves? Was it the trust themselves who decided to investigate SB and RJ through the disciplinary route?


YG described the attitude of the Consultants as "a witch hunt" in relation to LL.

• The Trust's Disciplinary Policy states: If there appears to be a criminal act, the Chief
Executive will consult the Police before invoking the Disciplinary Procedure. (A29)
• 1H stated "It felt purely circumstantial...we wanted more if we were going to call the
Police". IH expanded on this and described that the Executive team felt strongly that
if they raised concerns with the Police without foundation, LL would have been
arrested which would have resulted in a "bomb-site"(A3)

• AK stated that "it was talked about if we needed to go to the Police" (A4) and ELP
and YG both feel strongly that the group of consultants had 'threatened' to call the
Police if LL was not removed from the unit. IH stated that there was ""a block to that
[supervised practice] as the consultants were not prepared to have the nurse on the
unit and if we do, the Police will be called" and further confirmed that there was "an
unwritten threat to call the Police." (A3) SB and RJ refute this. SB was asked 'at no
time did the consultants as a group or individually suggest that if the executive board took no action the police would be called/' to which he responded "No" and further asked 'it was suggested that police would be called if LL not removed from unit. Do you recall that discussion?" and SB again answered "No" (Al2). RJ also denied that this was how conversation around calling the Police was had and in response to being asked if there was 'a suggestion that if Lucy was not moved then the police would be called?' stated `No. A discussion took place that if no explanation found, then the police may have to be involved. Don't recall any discussion as explicit as that."

The evidence suggests that, whilst the Executive team acknowledged and appreciated these concerns, their preliminary fact-finding did not produce any information that prompted them to initiate either a formal internal or Police investigation.

When asked about his concerns regarding LL, SB stated only "the association with
her being on shift and the death of the babies." RJ stated that "All that was said was that we had concerns. We noted the association with Lucy being present. Decisions made were entirely those made by Senior Management — no Clinicians were involved in the decision to remove Lucy from the unit. It was a Board decision."

SB stated that he would have 'issue' if LL was returned to the unit as he didn't feel the concerns the consultants had raised to the Executive team had "been fully
answered" and stated that these were concerns around the "association with her
being on shift and the deaths of the babies'. He stated that he had escalated these concerns to the Execs back in July 2015.
SB acknowledged that it was "conceivable" that the findings in the report could alleviate his concerns.

RJ stated that "If the Executive Board felt it was appropriate for her to return then she
would be back working on the unit. If subsequently there were further associations we would raise concerns but that would be speculation."

https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-evidence/INQ0002879_208-226.pdf

 

[Ruthbullock]

Any ideas why one line is highlighted red?

https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-evidence/INQ0010036.pdf