Tuesday, September 26, 2023

Nurse Lucy Letby Part I



 Lucy Letby (born 4 January 1990) is a British serial killer and former neonatal nurse who murdered seven infants and attempted to murder six others at the Countess of Chester Hospital between 2015 and 2016. Letby was the focus of much suspicion as the outbreak of unexpected collapses and infant deaths commenced shortly after she was qualified to work with children in the hospital’s intensive care unit and was consistently on duty when each incident took place. As soon as Letby was removed from duties in June 2016, the suspicious incidents stopped.

Letby was charged in November 2020 with eight counts of murder and ten counts of attempted murder. During her trial, which lasted from October 2022 to August 2023, it was revealed that Letby's methods included injecting the infants with air or insulin, overfeeding them, or physically assaulting them. She also stole over 250 confidential documents relating to the children's care to keep as mementos of her crimes and falsified patient records to avert suspicion. Several parents and staff members had also walked in during, or just after, Letby's attacks on victims. On 21 August 2023, Letby was sentenced to life imprisonment with a whole life order. She has announced her intention to appeal, while a retrial of one count of attempted murder is also planned.

Letby is the most prolific serial killer of children in modern British history; the Cheshire Constabulary now suspects that she may have claimed more victims, including at Liverpool Women's Hospital, where two babies died while she was training there. Management at the Countess of Chester Hospital was criticized for ignoring warnings about Letby that could have prevented some of the killings. The British government has since announced that an independent statutory inquiry would be held into the circumstances surrounding the murders.

Early life and education

Lucy Letby was born on 4 January 1990 in Hereford, Herefordshire, the only child of a finance manager and an accounts clerk. She was educated at Aylestone School and Hereford Sixth Form College. She had had a very difficult birth herself and was, according to a friend who had known her since secondary school, "very grateful for being alive to the nurses who would have helped save her life".  This, the friend states, had led her to want to be a nurse all her life and that "everything that she did was geared towards that ultimate goal of becoming a nurse". Letby pursued her education in nursing at the University of Chester, where she also worked as a student nurse during her three years of training, carrying out placements at Liverpool Women's Hospital and the Countess of Chester Hospital. Letby was the first member of her family to study at university and graduated in September 2011. A friend described her as "quite awkward and geeky".

Career

Letby began working as a registered nurse at the neonatal unit of the Countess of Chester Hospital in 2012. In a 2013 staff profile, she said that she was responsible for "caring for a wide range of babies requiring various levels of support" and that she enjoyed "seeing them progress and supporting their families." Letby also took part in a campaign to raise funds for a new neonatal unit at the hospital. Parents noted that Letby happily chatted about her life, such as telling them about how she was single and happy being single.

Letby had two training placements at Liverpool Women's Hospital, in late 2012 and early 2015, which came under investigation after her conviction. In June 2016, consultants asked management to remove her from clinical duties pending an investigation into her conduct. She had previously been moved from night to day shifts in April 2016 by the unit's ward manager. Letby was transferred to the patient experience team in July 2016 and later to the risk and patient safety office, working there until her arrest in 2018.

Letby had finally qualified to work with the infants who needed intensive care in 2015, the same year the suspicious incidents began. Letby had told others that she found non-intensive care work "boring" and sought the action of the intensive care unit. When she was moved to day shifts the suspicious incidents notably moved from occurring overnight to happening in the daytime when Letby was working.

Murders

Initial investigation

An informal review conducted in June 2015 by a consultant and lead neonatologist at the Countess of Chester Hospital NHS Foundation Trust revealed troubling details regarding four unexplained collapses that occurred in the same unit. Three of these cases resulted in deaths in the same month. It was observed that Letby had been on shift on each occasion. The unit's consultants promptly reported these deaths to the trust's committee responsible for addressing serious incidents. The committee classified the deaths as "medication errors". Had they been classified as "serious incident[s] involving unexpected deaths", an immediate investigation could have taken place if they were grouped together. The number of unexplained collapses was particularly abnormal: there had previously been only two or three deaths a year in the neonatal unit. What was also particularly unusual was that the babies did not respond to resuscitation attempts as they would be expected to.  Usually, babies that had a heartbeat back would see an improvement in their breathing, but that did not happen in these cases, which was distinctly unusual.  A misconception of the later Senior Investigating Officer on the case, Detective Superintendent Paul Hughes, was that sick babies in such a ward for vulnerable patients could collapse at any moment; in fact, baby collapses are usually expected beforehand. On the rare occasions when a collapse is not predicted, a medical explanation can usually be found, unlike in this case.

In October 2015, a ward manager conducted her own review, noting that Letby was the only staff member consistently present throughout these incidents of unexplained collapses and deaths. These findings were relayed to the lead neonatologist. Further concerns were voiced to management by the unit's consultants that same month; concerns were either resisted by the Trust Executives or ignored. In February 2016, the lead neonatologist, along with other consultants, concluded a thematic review investigating five unexplained deaths and collapses within the unit. Their investigation determined that the only common factor in these cases was the presence of Letby. The lead neonatologist communicated the findings via an "urgent" email to the trust's medical director leading to an eventual meeting in May 2016. The executive team deemed it to be coincidental and no substantial action was taken.

Reports by the Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK project (MBRRACE-UK) found a neonatal death rate at least 10% higher than expected between June 2015 and June 2016. Additionally, the neonatal death total in 2015 doubled that of the previous year. The mortality rate had risen above what might be considered 'normal' rates. During a hospital visit in February 2016, The Care Quality Commission (CQC) was informed of difficulties in raising concerns with managers but heard no mention of an elevated mortality rate. The CQC's report identified issues of "short-staffing" and "skill-mix" issues within the unit, yet it praised the overall positive culture of the trust, where "[s]taff felt well supported, able to raise concerns and develop professionally."

On 24 June 2016, following the deaths of two triplet babies on that day and the previous day, the lead neonatologist phoned the duty executive demanding that Letby be removed from the unit. The duty executive insisted that Letby was safe to work and that she was "happy to take responsibility" if anything happened to any more babies under Letby's care. In late June 2016, the trust's executive directors convened to address a critical decision: whether to involve law enforcement. By this time, seven unexpected deaths had taken place within the unit. The belief among these executives was that the indications of Letby's involvement were largely circumstantial and they suspected certain doctors of embarking on a misguided "witch hunt". Moreover, they were concerned about potential harm to the Trust's reputation resulting from a police inquiry. Ultimately, they opted against engaging the police. The medical director and chief executive instead organized a review through the Royal College of Paediatrics and Child Health (RCPCH), which was initiated in September 2016. At the same time, the unit's services were scaled back in July 2016, no longer accommodating premature births before the 32-week mark. Such cases were redirected to other hospitals in the North West of England, such as Alder Hey Children's Hospital.

The trust set a narrow scope for the review that excluded investigating Letby's actions or the deaths but instead focused on the unit's general service. The RCPCH reported its findings to the medical director and chief executive in October 2016. They could not find a definitive explanation for the increase in mortality rate at the unit but found some insufficient staffing and senior cover. The report recommended a detailed case review of each death. The medical director asked neonatologist Jane Hawdon from Great Ormond Street Hospital to carry out the case reviews. Hawdon responded she could not conduct a detailed review because of lack of time but could provide a summary and did so after briefly reviewing the notes. She identified four cases that "potentially benefit from local forensic review as to circumstances, personnel, etc". The board's chair at the time, has said that he was misled about the scope of that review and its findings. Despite the thorough external independent review recommended by the RCPCH or the forensic review recommended by Hawdon, records of the hospital board meeting show the medical director telling board members that the RCPCH and Hawdon reviews concluded that the deaths in the neonatal unit were due to issues with leadership and timely intervention.

 In September 2016, Letby raised a formal grievance about her late June 2016 transfer from clinical duties to the hospital's risk and patient safety office. This grievance was upheld by the board in January 2017, which determined her removal had been "orchestrated by the consultants with no hard evidence". They supported her return to the neonatal unit and offered her a placement at Alder Hey Children's Hospital in Liverpool plus support to develop advanced practice or a master's degree. The medical director also commented in the report that the trust's intention was to "protect Lucy Letby from these allegations". The chief executive had met with Letby and her parents on 22 December 2016 to apologize on behalf of the trust and assure them that the doctors who made the allegations would be "dealt with". He later ordered the consultants to send a letter of apology to Letby, which they did in February 2017.

In March 2017, consultants asked management to involve the police after receiving advice from the regional neonatal lead, who suggested further investigation was needed. They then met with Cheshire Constabulary on 27 April 2017, to raise their concerns, with Letby due to return to work on 3 May 2017. The trust publicly announced the involvement of the police in May 2017, stating this move was to "seek assurances that enable us to rule out unnatural causes of death." The police's investigation was called Operation Hummingbird. Senior Investigating Officer Paul Hughes later said: "The initial focus was around the hypotheses of what could have occurred: so generic hypotheses of 'it could be natural-occurring deaths', 'it could be natural-occurring collapses', 'it could be an organic reason', 'it could be a virus', and then one of the hypotheses was that, obviously, it could be inflicted harm."

Timeline of cases

The first suspicious case occurred on 8 June 2015. At 8 pm a healthy baby boy – a twin – was being cared for in nursery 1 on the ward and the designated nurse was Letby. The boy had been handed over to Letby after she started her night shift, with the pediatric registrar having clocked off when Letby was 30 minutes into her shift. 26 minutes later, she called a doctor with the baby's state rapidly deteriorating. The baby died half an hour later, less than 90 minutes into Letby's shift. The pediatric registrar later testified that when she heard about the death of the child the next day after returning to work it was a "big surprise" and "completely out of the blue and very upsetting. [He] showed no signs of any problems throughout the day. He was handling well. I had no concerns at all for him or his twin sister". A fellow nurse said that when the baby started deteriorating she saw Letby standing over the infant's incubator and originally did not intervene. However, the nurse then did when she realized he was not recovering under Letby's care. Doctors attending the scene said that Child A developed an unusual blue and white mottling on his skin after collapsing, which they said they had never seen before. This symptom later occurred in other babies that were believed to have been intentionally injected with air. The day after Child A's death, Letby searched for his parents on Facebook.

About 28 hours after Child A's death, his twin sister, Child B, also inexplicably collapsed and had to be resuscitated. After Child A's death, the parents had spent the day with Child B in the nursery but were persuaded to go and rest before the baby's sudden crash. Tests later showed loops of gas-filled bowel in the child. As a result, it was later concluded that the baby had been injected with air. Letby had fed the baby 25 minutes before their collapse and the child had the same unusual rash on her skin as first seen on Child A hours earlier, indicating that they had also been injected with air.

 A few days later, Child C, a boy in good condition, died. He suddenly collapsed as soon as another nurse left the nursery. Despite not being the designated nurse for the child, Letby was witnessed standing over his monitor as his alarm sounded when the other nurse came back in. Letby's shift leader had already told her to focus on her designated patient and the shift leader later testified that she had to keep pulling her away from the family room as Child C died. His parents later recalled a nurse they believe was Letby brought a ventilator basket in and said, even though their child was not dead, "You've said your goodbyes, do you want me to put him in here?".

On 22 June 2015, baby girl Child D collapsed three times in the early hours and died. Those who attempted to save the child noticed the girl's skin had been discolored. A post-mortem X-ray showed a 'striking' line of gas in front of the spine, consistent with air being injected into the bloodstream. A doctor later testified that such a finding could not be explained by natural causes. The mother had noted Letby "hovering around" the family hours before the baby collapsed.

On 2 July, a doctor raised his concerns over the sudden collapses and deaths. No action was taken against Letby. The suspicious cases stopped for a month. On 4 August 2015, a mother walked into the unit to give her baby boy, Child E, his milk, only to find Letby apparently in the process of attacking the child. She found the baby distressed and bleeding from the mouth, with Letby standing nearby "faffing around, not doing anything" and wanting "to look busy but not actually doing anything". The boy later died after suffering a fatal bleed, which was believed to have been the cause of death along with the injection of air. Flecks of blood were found in his vomit. The next evening, Child E's twin brother Child F was being cared for in nursery 2, the same room in which Letby was looking after another infant. At 1:54 am Child F suffered an unexpected drop in his blood sugar and saw a surge in his heart rate. The child survived and a blood test later revealed that he had been given an "extremely high" amount of exogenous pharmaceutical insulin, which he had never needed. No baby on the unit had been prescribed insulin at the time and so there was no reason why this baby should be given it. The insulin was kept in a locked fridge next to a nurses' station. Later, at trial, Letby did not contest that the baby had been intentionally injected with insulin, suggesting someone else must have done it. Letby searched for the parents of Child E and F on social media in the following weeks and months.

At this point the lead consultant made his feelings known that he was not happy with Letby working on the unit, but this was dismissed.

7 September 2015 was the 100th day of Child G being alive and the nurses had put up banners and made a cake for her parents to mark the day. On that same day, the child collapsed and did so again on two other occasions in the following three weeks. After the first collapse, the baby girl was taken to Arrowe Park Hospital, but five days later she collapsed again, 15 minutes after Letby had been feeding her. The child survived but is now severely disabled as a result of what happened to her. The baby has witnessed projectile vomiting so massively that it reached the chair next to the cot and canopy, which an attending doctor said he had never witnessed before. Her heart rate and oxygen levels also dropped to unusually low levels. The doctor said that he could not find a natural cause for the drastic vomiting. Later, at trial, an expert witness doctor concluded that the only viable explanation for the baby vomiting so extraordinarily was if she had received far more milk than that allocated down her feeding tube and that this could not have happened accidentally. It was later discovered that Letby had deliberately altered the baby's temperature on her observation chart to make it seem like she was already unwell before she collapsed, and also falsified the time of the baby's collapse to make it seem like it coincided with when a colleague gave the baby a milk feed. A nurse noticed when she arrived after crying for help after one of the baby girl's collapsed that the machine connected to the baby to measure its oxygen saturation and heart rate levels had been turned off. A colleague had also noticed that Child G's initial collapse occurred on the day she was originally due to be born.

About six weeks after Child G's multiple collapses, on 23 October 2015, Child I died. This was the fourth time the baby girl had collapsed. On the fourth collapse, Letby was found next to her incubator by another nurse. Letby later sent a sympathy card to the baby girl's parents on the day of her funeral, a card which Letby kept photos of on her phone. Letby also wanted to go to the funeral. Twice the baby was found to have excess air in her stomach which had affected her breathing. Before the second collapse, Letby had said to a colleague that Child I 'looked pale', even though it would have been hard to see from where they were standing in a doorway looking into the darkened nursery. Then, when the designated nurse for the child turned the light on, she saw the girl was not breathing. The child's mother later said Letby 'smiled' as she bathed her dead daughter and offered to take a photo of the dead child. A doctor had seen unusual skin mottling on Child I's skin and X-rays showed the child had a massively enlarged stomach that was consistent with her having been deliberately injected with air. Letby later searched for Child I's mother on Facebook.

Later on 23 October, the hospital management was alerted to the concerns of the doctors on the unit. They were told to "not make a fuss". Staff reviews were carried out which highlighted that Letby was always on duty for the suspicious incidents and in February 2016 a doctor requested an "urgent" meeting with executives, but no meeting occurred until May 2016.

At 11:26 pm on Christmas Day 2015, Letby searched on Facebook for the parents of the twins, Child E and Child F.

By April 2016, Letby had been moved to day shifts because of the concerns about her and the suspicious collapses began occurring in the daytime. On 9 April 2016, two twin brothers suffered sudden collapses within hours of each other. Tests found that Child L inexplicably had insulin levels in his blood "at the very top of the scale that the equipment was capable of measuring". Hours later, twin brother Child M's heart rate and breathing suddenly dropped and he nearly died. Experts said that Child M's heart was likely caused by air being injected into his bloodstream.  Although he lived, the child suffers from brain damage. It was noted that the collapses of Child L and M occurred in almost identical circumstances to Child E and F. Both were twins where one was believed to have been injected with insulin and the other with air. Child F had survived his injection of insulin and it was noted that Child L had been injected with twice the dose of insulin, the suggestion being that Letby had done so to ensure death on this occasion.

A meeting about the suspicious cases took place on 11 May 2016, but no action was taken.

A month later, Child N nearly died after suffering trauma to the throat. Doctors saw blood and "unusual" swelling at the back of his throat upon examination. The baby had been heard randomly 'screaming'. Child N's father said he then saw blood spattered around his son's mouth.

The final two cases occurred within hours of each other on 23 and 24 June 2016. The two children involved were triplets, siblings of each other, and the cases occurred on Letby's first shift back after she had returned from a trip abroad to Ibiza and after Letby texted a colleague saying she would "be back with a bang". Child O, a "perfect" healthy baby, was due to be discharged home, but suddenly collapsed on 23 June. When the child initially became unwell, another nurse suggested he be moved to nursery 1 where the sickest children were treated, but Letby disagreed and the baby subsequently collapsed less than two hours later. He recovered but suffered two further collapses and died almost exactly three hours later. The lead consultant noted that the child "should have responded better"  to resuscitation. X-rays on a post-mortem showed he had an abnormal amount of gas in his body and liver damage that an independent pathologist later ruled had resulted from an "impact injury" similar to what would be seen in a car crash. 13 minutes after Child O's death, Letby was feeding his triplet brother Baby P, who also was expected to be able to soon go home, but he collapsed after his diaphragm was somehow shattered.  Doctors attempted to recover him by preparing him to go to another hospital and Letby then remarked "he's not leaving here alive, is he?” The boy soon died. X-rays likewise showed an inexplicable amount of gas inside the baby. These deaths have been described as "exceptional" and the "tipping point" when the consultants realized that "drastic" action needed to be taken.  A consultant allowed the surviving triplet to be taken to a different hospital by medics who had turned up to take Baby P, who had been expected to live. The consultant said she allowed this after her parents begged for it, as she now felt Letby was a "mortal danger" to the surviving triplet. Before the second triplet died, Letby had texted a doctor saying she would "be watching them both [Child P and the surviving triplet] like a hawk" and said, "I'm OK. Just don't want to be here really. Hoping I may get the new admissions".

Three weeks later, in July 2016, Letby was removed from duty and the suspicious collapses stopped.

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