Across the period in question there were 17 deaths. LL was charged and convicted of 7 of those. What caused the rest of them?
It’s interesting to note that during the year of the death spike the consultants were only on the unit for 2 ward rounds per week vs the Royal College recommended 2 ward rounds per day. An RCPCH report found that the acuity of neonatal care in the unit demanded greater consultant presence. The RCPCH also noted that staffing was dominated by junior and training doctors, supplemented heavily by locum cover. Leadership in the unit was characterised as remote.
Also that year (a non exhaustive list):
There was raw sewage backing up into toilets and the handwashing basin in the nursery.
A bug called pseudomonas, which is lethal to neonates and has caused several spates of deaths in other NICUs, was identified in 2 taps in the COCH NICU. The taps were not replaced for “capacity” (cost) reasons.
One parent saw staff googling how to do a lung drain on her baby, following an online tutorial in a panic.
Other parents described a dirty, cold, unhygienic unit in need of serious updating.
An RCPCH review identified a 21% staffing shortfall in the COCH neonatal unit during the period when the baby deaths occurred. This level of under‑staffing deviated from national safe‑staffing guidance.
In a board meeting in January 2016, executives were warned the service was “almost at breaking point” and at risk of burnout. That staff were overworked and sometimes “in tears” with stress.
Also interesting to note that Dr Brearey was the Unit Lead (a management position btw) at COCH NICU during this time. He was the named clinician responsible for governance and safety within the unit.
Unit Lead is a role which includes:
- Setting and enforcing clinical protocols and standards of care within the unit.
- Deciding how adverse events, complaints, or near-misses are investigated and followed up.
- Ensuring compliance with national guidelines (NICE, GMC, Royal College standards).
- Deciding on equipment procurement priorities and business cases to hospital management.
- Providing the clinical evidence and argument for why the unit should be upgraded (e.g. enough staff, outcomes data, ability to meet standards).
- Making decisions about rota planning, ensuring safe cover by consultants, registrars, junior doctors, and advanced nurse practitioners.
- Being accountable for the performance of the whole unit.
In short, the Unit Lead is responsible for making strategic, governance, staffing, and protocol-level decisions that shape the safe running of the unit. They also have authority in disputes, and their voice carries weight in whether concerns get escalated or quietly managed internally. I’ll let you ponder on how well all of the above was managed.
Meanwhile Dr Ravi Jayaram was very busy that year making a tv show and appearing on morning talk shows.
They both chose to email upper management for over a year instead of escalating the deaths they now say were “unexpected” and “unexplained” to the coroner, the Pan Cheshire Child Death Panel, or the police, despite (we are asked to believe) being sure that LL was murdering babies in the NICU and despite it being their clinical responsibility to report suspected harm, regardless of what a manager’s email said. But they didn’t.
In fact Brearey actually refused to share what he called “a drawer of doom” full of evidence with management.
I have serious concerns about the decisions these men (and other doctors) made during this time. My concerns only worsen (they don’t lessen!) if LL actually was simultaneously murdering babies while this poorly run hospital, foolishly upgraded to a LNU beyond its capacities, was simultaneously causing other deaths, coincidentally.
I don’t know how anyone honestly doesn’t share these doubts, regardless of their opinions on the guilt/innocence of Lucy Letby.