Doctors' warnings ignored as Letby killed more babies - BBC investigation

Hospital bosses failed to analyse allegations against Lucy Letby and tried to soundlessness doctors, the pb advisor astatine the neonatal portion wherever she worked has told the BBC.

The infirmary besides delayed calling the constabulary contempt months of warnings that the caregiver whitethorn person been sidesplitting babies.

The unit's pb advisor Dr Stephen Brearey archetypal raised concerns astir Letby successful October 2015.

No enactment was taken and she went connected to onslaught 5 much babies, sidesplitting two.

Letby has been recovered blameworthy of murdering 7 babies and attempting to execution six others successful a neonatal portion astatine the Countess of Chester Hospital's, successful Cheshire.

The archetypal 5 murders each happened betwixt June and October 2015 and - contempt months of warnings - the last 2 were successful June 2016.

BBC Panorama and BBC News person been investigating however Letby was capable to execution and harm truthful galore babies for truthful long.

We spoke to the pb advisor successful the portion - who archetypal raised concerns astir Letby - and examined infirmary documents. The probe reveals a catalogue of failures and raises superior questions astir however the infirmary responded to the deaths.

Dr Brearey says helium demanded Letby beryllium taken disconnected work successful June 2016, aft the last 2 murders. Hospital absorption initially refused.

The BBC probe besides found:

Before June 2015, determination were astir 2 oregon 3 babe deaths a twelvemonth connected the neonatal portion astatine the Countess of Chester Hospital. But successful the summertime of 2015, thing antithetic was happening.

In June alone, 3 babies died wrong the abstraction of 2 weeks. The deaths were unexpected, truthful Dr Stephen Brearey, the pb advisor astatine the neonatal unit, called a gathering with the portion manager, Eirian Powell, and the hospital's manager of nursing Alison Kelly.

"We tried to beryllium arsenic thorough arsenic possible," Dr Brearey says. A staffing investigation revealed Lucy Letby had been connected work for each 3 deaths. "I deliberation I tin retrieve saying, 'Oh no, it can't beryllium Lucy. Not bully Lucy,'" helium says.

The 3 deaths seemed to person "nothing successful common". Nobody, including Dr Brearey, suspected foul play.

But by October 2015, things had changed. Two much babies had died and Letby had been connected displacement for some of them.

By this point, Dr Brearey had go acrophobic Letby mightiness beryllium harming babies. He again contacted portion manager Eirian Powell, who didn't look to stock his concerns.

In an email, from October 2015, she described the relation betwixt Letby and the unexpected babe deaths arsenic "unfortunate". "Each origin of decease was different," she said, and the relation with Letby was conscionable a coincidence.

Senior managers didn't look to beryllium worried. In the aforesaid period - October 2015 - Dr Brearey says his concerns astir Letby were relayed to manager of nursing Alison Kelly. But helium heard thing back.

Dr Brearey's chap consultants were besides disquieted astir Letby. And it wasn't conscionable the unexpected deaths. Other babies were suffering non-fatal collapses, meaning they needed exigency resuscitation oregon assistance with breathing, with nary evident objective explanation. Letby was ever connected duty.

In February 2016, different consultant, Dr Ravi Jayaram, says helium saw Letby lasting and watching erstwhile a babe - known arsenic Baby K - seemed to person stopped breathing.

Dr Brearey contacted Alison Kelly and the hospital's aesculapian manager Ian Harvey to petition an urgent meeting. In aboriginal March, helium besides wrote to Eirian Powell: "We inactive request to speech astir Lucy".

Three months went by, and different 2 babies astir died, earlier successful May that twelvemonth Dr Brearey got the gathering with elder managers helium had been asking for. "There could beryllium nary uncertainty astir my concerns astatine that meeting," helium says.

But others astatine the gathering appeared to beryllium successful denial. Dr Brearey said Mr Harvey and Ms Kelly listened passively arsenic helium explained his concerns astir Letby. But she was allowed to proceed working.

By aboriginal June, yet different babe had collapsed. Then, towards the extremity of the month, 2 of 3 premature triplets died unexpectedly wrong 24 hours of each other. Letby was connected displacement for some deaths.

After the decease of the 2nd triplet, Dr Brearey attended a gathering for traumatised staff.

He says portion others seemed to beryllium "crumbling earlier your eyes almost", Letby brushed disconnected his proposition that she indispensable beryllium bushed oregon upset. "No, I'm backmost connected displacement tomorrow," she told him. "She was rather blessed and assured to travel into work," helium says.

For Dr Brearey and his chap consultants, the deaths of the 2 triplets were a tipping point. That evening, Dr Brearey says helium called work enforcement Karen Rees and demanded Letby beryllium taken disconnected duty. She refused.

Dr Brearey says helium challenged her astir whether she was making this determination against the wishes of 7 advisor paediatricians - and asked if she would instrumentality work for thing that mightiness hap to different babies the adjacent day. He says Ms Rees replied "yes".

The pursuing day, different babe - known arsenic Baby Q - astir died, again portion Letby was connected duty. The caregiver inactive worked different 3 shifts earlier she was yet removed from the neonatal portion - much than a twelvemonth aft the archetypal incident.

The suspicious deaths and collapses past stopped.

Letby inactive wasn't suspended, however.

Instead, she was moved to the hospital's hazard and diligent information office. Here she is believed to person had entree to delicate documents relating to the hospital's neonatal unit. She besides had entree to immoderate of the elder managers whose occupation it was to analyse her.

On 29 June 2016, 1 of the consultants sent an email nether the taxable line: "Should we notation ourselves to outer investigation?"

"I judge we request assistance from extracurricular agencies," helium wrote. "And the lone bureau who tin analyse each of us, I believe, is the police."

But infirmary managers thought otherwise. "Action is being taken," wrote aesculapian manager Ian Harvey successful his reply. "All emails cease forthwith."

Two days later, the consultants attended a gathering with elder management. They accidental the caput of firm affairs and ineligible services, Stephen Cross, warned that calling the constabulary would beryllium a catastrophe for the infirmary and would crook the neonatal portion into a transgression scene.

Rather than spell to the police, Mr Harvey invited the Royal College of Paediatrics and Child Heath (RCPCH) to reappraisal the level of work connected the neonatal unit.

In aboriginal September 2016, a squad from the Royal College visited the infirmary and met the paediatric consultants.

The RCPCH completed its study successful November 2016. Its recommendations included: "A thorough outer autarkic reappraisal of each unexpected neonatal death."

In October 2016, Ian Harvey besides contacted Dr Jane Hawdon, a premature babe specializer successful London, and asked her to reappraisal the lawsuit notes of babies who had died connected the neonatal unit.

The effect was a highly caveated report. According to Dr Hawdon, her study was "intended to pass treatment and learning, and would not needfully beryllium upheld successful a coroner's tribunal oregon tribunal of law".

It was not the thorough reappraisal the consultants had wanted - oregon the thorough outer autarkic reappraisal that the RCPCH had recommended. But adjacent the constricted case-note study by Dr Hawdon recommended that 4 of the babe deaths beryllium forensically investigated.

In aboriginal January 2017, the infirmary committee met and Mr Harvey presented the findings of the 2 reviews. Both had recommended further probe of immoderate of the babe deaths - and yet that connection did not scope committee members.

Records of the gathering amusement Mr Harvey saying the reviews concluded the problems with the neonatal portion were down to issues with enactment and timely intervention.

A fewer weeks later, successful precocious January 2017, the 7 consultants connected the neonatal portion were summoned to a gathering with elder managers, including Mr Harvey and the hospital's CEO Tony Chambers.

Dr Brearey says the CEO told them helium had spent a batch of clip with Letby and her begetter and had apologised to them, saying Letby had done thing wrong.

According to the doctor's account, the CEO besides insisted the consultants apologise to Letby and warned them that a enactment had been drawn and determination would beryllium "consequences" if they crossed it.

Dr Brearey says helium felt managers were trying to "engineer immoderate benignant of narrative" that would mean they did not person to spell to the police. "If you privation to telephone that a cover-up then, that's a cover-up," helium says now.

Managers besides ordered 2 of the consultants to be mediation sessions with Letby, successful March 2017. One of the doctors did beryllium down with the caregiver to sermon her grievance, but Dr Brearey did not.

Yet, the consultants didn't backmost down. Two months aft the apology, the infirmary asked the constabulary to investigate. It was the consultants who had pushed them into it.

Dr Brearey and his colleagues yet sat down with Cheshire Police a mates of weeks later. "They were astonished," helium says.

The adjacent day, Cheshire Police launched a transgression probe into the suspicious babe deaths astatine the Countess of Chester Hospital. It was named Operation Hummingbird.

Letby had not yet been arrested and was inactive moving astatine the hospital's hazard and diligent information office. But Operation Hummingbird was successful afloat plaything and Dr Brearey was helping the constabulary with their investigation.

Late 1 evening, helium was going done immoderate historical aesculapian records erstwhile helium discovered a humor trial from 2015 for 1 of the babies connected his unit. It recorded unsafe levels of insulin successful the baby's bloodstream.

The value of the trial effect had been missed astatine the time.

The assemblage produces insulin naturally, but erstwhile it does, it besides produces a substance called C-Peptide. The occupation with the insulin speechmaking that Dr Brearey was looking astatine was that the C-Peptide measurement was astir zero. It was grounds the insulin had not been produced people by the baby's assemblage and had alternatively been administered.

"It made maine consciousness sick," Dr Brearey recalls. "It was rather wide that this babe had been poisoned by insulin."

A fewer months later, Letby was yet arrested and suspended by the hospital. But 3 years had passed since Dr Brearey had archetypal sounded the alarm.

When a caller aesculapian manager and lawman main executive, Dr Susan Gilby, began enactment the period aft Letby's arrest, she was shocked astatine what she found.

She says her predecessor, Mr Harvey, had warned her she would request to prosecute enactment with the General Medical Council, the doctor's regulator, against the neonatal unit's consultants - those who had raised the alarm.

However, wrong a container of files near successful his office, she recovered grounds the problems laic elsewhere. Marked with the connection "neonates", the files revealed however a gathering of the enforcement squad successful 2015 had agreed to person the archetypal 3 deaths examined by an outer organisation. That ne'er happened.

The absorption squad had besides failed to study the deaths appropriately. It meant the wider NHS strategy could not spot the precocious fatality rates. The committee of the infirmary spot was besides unaware of the deaths until July 2016.

Dr Gilby says the trust's refusal to telephone constabulary appeared to beryllium heavy influenced by however it would look. "Protecting their estimation was a large origin successful however radical responded to the concerns raised," she says.

Later successful 2018, aft Tony Chambers resigned, Dr Gilby was appointed main enforcement and she stayed successful station until 2022. She is present suing the spot for unfair dismissal.

Dr Brearey, says infirmary managers had been "secretive" and "judgemental" passim the play starring up to the nurse's arrest.

"There was nary credibility fixed to our opinions. And from January 2017, it was intimidating, and bullying to a definite extent," helium tells BBC News. "It conscionable each struck maine arsenic the other of a infirmary you'd expect to beryllium moving in, wherever there's a harmless civilization and radical consciousness assured successful speaking out."

Letby would yet beryllium charged with 7 murders and 15 attempted murders betwixt June 2015 and June 2016.

She was recovered blameworthy of each 7 murders and 7 attempted murders. She was recovered not blameworthy of 2 counts of attempted murder.

The assemblage besides failed to scope a verdict connected a further six counts of attempted murder, including each charges related to babies K and Q.

The BBC contacted the spot which runs the infirmary and elder managers who were successful station during the play erstwhile the murders occurred, but they declined to remark up of the verdict.

Tony Chambers, the CEO astatine the time, said his thoughts are with the bereaved families.

The Countess of Chester Hospital is present nether caller absorption and the neonatal portion nary longer looks aft specified sick babies. Since Letby near the unit, determination has been lone 1 decease successful 7 years.

Editing and accumulation by Joseph Lee