Government Urged to Upgrade Inquiry After Conviction of Serial Baby-Killer Nurse Letby

Lucy Letby is led away in handcuffs by police after being arrested at her home in Chester, England, on July 3, 2018. Cheshire Police

The government has ordered an independent inquiry on Friday after neonatal nurse Lucy Letby was found guilty of murdering seven babies in around one year, but was told the non-statutory inquiry is “not good enough.”

Lawyers representing some of the victims’ families called for a full public inquiry that they say would “have real teeth.”

Letby, 33, who worked on a special unit for premature babies at the Countess of Chester Hospital in the north of England, has been found guilty of murdering seven infants and attempting to murder another six between June 2015 and June 2016.

The court heard Letby had used a variety of ways to kill the infants, such as injecting air into their bloodstream, pushing air into their stomach, poisoning them with insulin, overfeeding them with milk, or manipulating their feeding or breathing tubes.

She was described by a lead police investigator as “beige” and having nothing unusual in her life. Her motivation has not been established in the case but some experts believe she has the hallmark of someone with Munchausen syndrome by proxy, where a parent or carer makes a child in their care ill or, in extreme cases, causes their death in order to get attention.

Letby is due to be sentenced at Manchester Crown Court on Monday and will likely spend most of her life in prison.

A courtroom sketch of Lucy Letby to a question from her barrister Ben Myers KC at her trial at Manchester Crown Court in Manchester, England, on May 17, 2023. PA

During the trial, the court heard that doctors at the hospital had raised “significant concerns” as early as autumn 2015 over unexplained baby collapses and deaths, in which Letby was the common denominator. Their concerns reached a “tipping point” in June 2016, but it took the hospital another 11 months before they called the police.

Following Letby’s conviction, the Department of Health and Social Care (DHSC) ordered an independent inquiry into “the wider circumstances around what happened at the Countess of Chester Hospital, including the handling of concerns and governance,” and “what actions were taken by regulators and the wider NHS.”

Expressing “deepest sympathy” to the victims’ families, Health and Social Care Secretary Steve Barclay said the inquiry will “seek to ensure” they “get the answers they need.”

“I am determined their voices are heard, and they are involved in shaping the scope of the inquiry should they wish to do so,” Mr. Barclay said.

“Following on from the work already underway by NHS England, it will help us identify where and how patient safety standards failed to be met and ensure mothers and their partners rightly have faith in our healthcare system,” he said.

The inquiry will be non-statutory, which the DHSC said is “the most appropriate.”

“After careful consideration, a non-statutory independent inquiry was found to be the most appropriate option, building on the approach taken in other cases. It will focus on lessons that can be learned quickly,” the department said in a statement.

Non-Statutory ‘Inadequate’

Lawyers representing the families of two victims have called on the government to make the inquiry statutory.

In a joint statement Richard Scorer, head of abuse law and public inquiries, and Yvonne Agnew, head of clinical negligence Cardiff, at law firm Slater and Gordon, said a non-statutory inquiry is “inadequate” because it “does not have the power to compel witnesses to provide evidence or production of documents and must rely on the goodwill of those involved to share their testimony.”

“This is not good enough. The failings here are very serious and an inquiry needs to have a statutory basis to have real teeth,” the statement said.

The lawyers also said NHS’s “duty of candour” appears to have failed in this case, “with hospital managers seemingly prioritising the hospital’s reputation above child safety.”

“We do not believe that ‘duty of candour’ is an adequate substitute for a proper mandatory reporting regime, and any inquiry needs to examine this issue properly as failings here could be replicated elsewhere in the NHS,” they said.

Samantha Dixon, Labour MP for Chester, also BBC Breakfast that she had written to Mr. Barclay to raise her concerns about the inquiry being non-statutory.

Steve Brine MP, Conservative chair of the Health Select Committee, shares the concerns, telling BBC Radio 4’s “Broadcasting House” programme on Sunday that he can’t see how “anything other than a proper judge-led statutory inquiry” would restore public confidence.

Babies A–Q

Letby was formally identified as a suspect in Cheshire police’s Operation Hummingbird on July 3, 2018, around 14 months after the hospital called the police over the spiking number of baby deaths and non-fatal collapses in a little over a year.

The police said they spoke to around 2,000 people and reviewed tens of thousands of evidence including medical records.

Letby was eventually charged with the murder of eight babies as well as 15 counts of attempted murder involving 10 babies, all of which she denied.

In June 2022, Letby was cleared of one murder charge.

Undated handout photo issued by the Crown Prosecution Service (CPS) of a note found in the house of Lucy Letby, the nurse accused of murdering seven babies and trying to kill 10 more wrote "I am evil I did this" in capital letters on a piece of paper found after a police search of her house, a court has heard, issued on October 13, 2022.

Following 22 days of deliberation that ended on Friday, Juries found her guilty of 14 charges, including:

• The murder of seven babies: boys A, C, E, O, P, and girls D and I.
• The attempted murder of six babies: boys F, L, M, N, and girls B and G (two counts).

She was cleared of two charges, including:

• One attempted murder charge involving baby G.
• One attempted murder charge involving baby H.

Juries haven’t been able to reach a verdict on another six counts of attempted murder of babies H, J, K, N (two counts), and Q.

The children or their parents can’t be named because of the court’s reporting ban.

Nicholas Johnson KC, prosecuting, has asked the court for 28 days to consider whether a retrial would be sought for the remaining six counts of attempted murder.

Senior investigating officer Det. Supt. Paul Hughes told the PA news agency on Friday that detectives are continuing to review “every single baby’s admission into neonatal unit” throughout Letby’s career, which was around 4,000.

The period covers her spell at the Countess of Chester Hospital from January 2012 to the end of June 2016 and includes two work placements at Liverpool Women’s Hospital in 2012 and 2015.

Cheshire Police emphasised that only those cases highlighted as medically concerning would be investigated further.

Det. Supt. Hughes also said detectives won’t be “narrowing it down to Lucy Letby” and will examine other concerns that emerge during the review.

Alarm Raised Months Before Police Involvement

Speaking after the convictions, senior investigating officer Detective Chief Inspector Nicola Evans said Letby’s motive may never be revealed “unless she chooses to tell us.”

“There isn’t anything outstanding or outrageous that we found about her as a person,” he said.

“And I think that has come across during the trial in that she was an average nurse, a normal 20-something,” he said.

The only red flag that emerged in the early days was that Letby was the only nurse on duty in all the cases.

During the 10-month trial, paediatricians at the hospital told the court that they had been suspicious of Letby for almost two years before police were called, but they were not believed and had been told to apologise to Letby in writing at one point.

Dr. Stephen Brearey, the head consultant in charge of the hospital’s neonatal unit, first raised concerns in the summer 2015 after reviewing three baby deaths that occurred over two weeks in June and found that Letby was on duty in all three cases.

But in an interview with the BBC, Dr. Brearey said no one, including him, suspected foul play at that point.

The broadcaster said that before 2015 the hospital only had two to three neonatal deaths a year.

By October, other doctors had become suspicious following two more deaths and more non-fatal collapses.

Consultant paediatrician Dr. Ravi Jayaram told the court that they raised “significant concerns” that were passed on to an executive director of nursing in October 2015 but “the initial response was ‘It’s unlikely that anything is going on. We’ll see what happens.'”

Dr. Brearey went on to commission an independent neonatologist from Liverpool Women’s Hospital to analyse the increased mortality rate, but the review came back inconclusive in February 2016.

However, concerns remained about Letby as a “common link” during all the collapses and deaths as Dr. Brearey sent copies of the report to nursing director Alison Kelly and medical director Ian Harvey.

Dr. Jayaram told the court there was no response from bosses for another three months.

An undated image of a photograph of a sympathy card Lucy Letby sent to the parents of one of her victims. The photo was found on Letby's phone when she was arrested in Hereford, England, in 2018. Cheshire Police/CPS

Another consultant, Dr. John Gibbs told the court that a “tipping point” was reached in June 2016 after two two triplet boys, Child O and P, died on successive days.

Letby was then moved to clerical duties in July 2016 after the whole neonatal consultant body convened for a meeting.

Dr. John Gibbs told jurors in March that hospital bosses wanted Letby back in the neonatal a month later but the doctors insisted that she shouldn’t be allowed back unless CCTV was put in each room.

“The CCTV didn’t come and neither did staff nurse Letby,” he said.

Letby filed a complaint in September 2016 after learning of the allegations against her.

It emerged during legal argument in court—in the absence of the jury—that the grievance procedure was resolved in Letby’s favour in December 2016.

Letby was due to return to the neonatal unit in March 2017 but the move did not take place and, soon afterward, police were contacted by the hospital trust.

However a number of consultants were also required to apologise to Letby formally in writing, the court heard.

According to the Crown Prosecution Service, key evidence against Letby included medical records including several documents they said were tampered by Letby, staff rotas, and Letby’s text messages, handwritten notes and diaries, and social media activity.