Culpability of consultants in Letby case

[curaçao]

Why did any of the 7 consultants who suspected Letby nit go to the police themselves? If you had strong suspicions that someone had committed murders, wouldn't you feel you had a strong moral duty to go to the police? OK maybe it was protocol to report it to managers, but surely they had a moral duty to whistleblow and report their suspicions to the police
But they are trying very hard to deflect blame onto managers who wouldn't even have known Letby nor understood the medical stuff

They thought they could do more to save and protect lives by keeping their jobs. And they were right.

There are some important points being overlooked here. The Director of Nursing is a highly qualified and experienced Nurse! The Director of Medicine is a very experienced Doctor. They are not some lower species of “management” who know nothing. What they could not do is “think the unthinkable”. They saw Letby’s bullying allegations as more important than the consultants’ concerns. The people who reach Director level, to some extent, leave certain standards behind. They become part of the “group think” that afflicts the NHS. It believes in its own strategies more than thinking outside the box. All these managers are insiders. They are slow to change and act and are part of the culture that allows a LL to get away with it. The consultants were marginalized and effectively threatened.

I’ve been a whistleblower in a different context. It took me a long time to be sure about what I needed to do, I went through a phase of thinking it was my problem, then a phase of thinking I could help bring about a solution as I believed the people causing the issue must be misguided/incompetent rather than malicious, and then a phase of slowly become more sure that this was definitely a problem. It sounds simple even putting it like that but I can tell you it was such a headfuck, for want of a better word. It was made more complex by the fact the “group” were on step ahead of me in trying to neutralise people who were suspicious of them. They had sowed a lot of seeds in the organisation to cast doubt/blame on me and fellow dissenters - these seeds affected us to where we questioned our own judgement or motivations as well as making our work context feel destabilised and confusing. Added to that, I can see in hindsight how early on the “group” insidiously hinted that they felt bullied, harassed, or undermined - way before I’d got to the phase of realising there was definitely a problem and this further muddied my thinking and slowed down my progression to my eventual conclusion that this was a situation that I needed to blow the whistle on. I left the job at the same time that I did that - I can’t imagine what the consequences for me would have been had i remained. The things the group had set in place regarding my competence and their “harassment” would have had a long impact I think. Whistleblowing is usually at best the start of a long slow remedy so it’s not as if you’re immediately vindicated or protected. In fact, as far as I know, it’s all still going on 18 months later.

I just thought I’d add this personal perspective of being a whistleblower. However I started typing this hours ago and then it didn’t post so it may be the thread has moved on significantly. Apologies if now irrelevant.

You have no idea what their motives were regarding not contacting the police so why make the assumption?

If I called the police about a colleague, having previously been told they had been investigated and exonerated, and told to drop it on pain of GMC referral, I would fully expect to lose my job, yes.

Obviously if I thought somebody was deliberately killing babies I would still do it, but if I thought they were just a bit shit at their job, which is unfortunately not a police matter or often even a sacking matter, I’d probably stay quiet but keep a very close eye on her.

@anunlikelyseahorse I didn't apply - I was the only consultant there and they asked me to do it on an interim basis while they recruited someone. As the only consultants who we managed ti recruit were even less experienced than me, I got kept on as interim. Then eventually the interim bit was dropped. I've now been in the role three years and when I go back I feel finally that I can do the job.

Wasn’t the senior manager a previous orthopaedic surgeon

The parents were given a choice. The professionals advised that nothing new would be learned. Many parents decided against guided by the professionals.

The Medical Director was an orthopaedic surgeon. Typically MDs continue their clinical practice alongside their executive role. The ones I’ve worked with have been obstetricians, ophthalmologists and dermatologists.

Op I agree to some extent. I understand they followed the usual hospital
protocol and were under pressure from their management team at the hospital. I don’t imagine going to the police independently would have been easy at all. However I would have thought that multiple consultants, with such truly serious concerns, would have found a way to otherwise escalate those concerns either by police or media or some other route. I mean these are clearly intelligent and very capable individuals. I find it scary when even people as intelligent as these consultants are feel they must follow every direction from their management team.

I don’t think it is the consultants “fault” but clearly there is a systemic issue that needs attention if people with the most expertise do not have the power to escalate concerns like these due to barriers from management.

Hmm, I think deep down they did suspect deliberate behaviour.

In one of the emails, they request that an external agency, eg the police look into it as they were all under suspicion and the police could look into their lives outside of work.

Dr Steve Brearey also commented in the Panorama documentary that he found LL's behaviour in a follow-up meeting to some of the deaths quite detached, was the only one not upset and thought it odd that she wanted to work the following day.

@Salacia

Very interesting about the GMC. Thankyou for posting that.

I agree. I also agree that it would have been incredibly difficult to go against senior management, particularly with the threats of GMC and they probably would have been questioning themselves, both because of the view of senior management and also because of how unbelievable the actions were.

But I also think deep down they knew they were right. I also think the police would have taken them and it seriously.

I guess what stopped them was the repercussions of a huge police investigation if that 1% of doubt was correct.

What was the cause of death for these babies.
Was teh pathologist at the hospital - surely they would raise questions at so many deaths.

Suspicions about LL aside, why wasn’t anyone in the trust saying, hang on a minute. Why do we have a very high number of deaths going on? More than other neonatal units. Why wasn’t someone getting to the bottom of it? I thought this had happened and the evidence led to her. Not for one minute did I think it took a couple of years of 7 distraught consultants all saying the same thing, before it got looked at.

Hiw eventually did the hospital come to the conclusion that it was probably her? What was the breaking point?

Except the majority of these babies, as described by the consultants, were stable and doing well at the time of collapse. One murder/attempted murder even happened on his day of release!

I think a lot of people on this thread are not understanding that premature babies, especially very premature babies have a fairly high death rate, sad as that is, so these deaths didn't in themselves arouse suspicion (they did eventually due to the change to the usual baseline death rate of course, but people need to understand that is absolutely not zero or anything close to it).

And that although technically parents do not need to consent to a coroner’s post mortem (they do for a hospital one), if families are against it (which is the overwhelming majority of families these days for any relative, let alone their prem baby that they have birth to a few weeks ago unexpectedly not much more than halfway through their pregnancy, and especially so since the Alder Hey scandal) it feels emotionally and psychologically cruel to insist without very good reason.

Doctors and coroners are human beings too and are influenced by these factors. I have worked in a SCBU setting. Imagine you are on the other side of this, as the mother, having just lost your very wanted (often IVF conceived) prem baby, and the medical establishment insisting on a post mortem against your will even though there is no suspicion of foul play (at the time). And you can’t have your baby’s body or organise a funeral until that is done, and you will get your baby’s body back in the best condition possible after that but there will be no disguising that a post mortem has been done and you will have the knowledge that some of their tissues may have been removed etc. For some religions the time to burial/cremation or removal of body integrity is a particular sticking point also.

It does happen this way at times of course, but the coroner has to have pretty strong reasons to mandate a post mortem on this scenario against the parents will. In retrospect of course they had a very good reason but this wasn’t clear at the time.

Most of these babies were expected to survive though. It’s what caused Dr Brearey’s suspicions when three babies died within a month - that was the usual annual death rate. So whilst very premature babies often die, the COCH did not usually take those babies. They were a grade two unit. These babies were expected to live. They were dying, but it was not obvious why. Letby’s Modus Operandi was so subtle. Brearey quickly noticed the Letby link after the third death but management failed to listen for a year.

They would likely have been suspended or sacked and there'd have been less people around to protect those babies. A lot of people behaved against what you'd expect in this case but it was Letby who murdered

I vaguely know one of the consultants who was a tiny bit involved (son of a family friend so see rarely at family gatherings but don’t have a phone number). He was there temporarily and contacted management after two of his patients got ill, but was told not to get involved and was not asked to work there again. He said he was concerned there was an issue but thought it was more incompetence than intention so hoped they’d deal with it privately. I know he feels awful about it now and wishes he had done more, but who would have thought that was what was happening?

Just to add to the comments re why wasn’t there a postmortem. As already noted, the mode of murder (air embolism in many cases) is very difficult to prove at diagnosis (especially if you’re not expecting it, you have to do specific tests for it). There is a huge shortage of paediatric pathologists in the UK (here if anyone wants to listen). This means that children and babies are having to go to mortuaries miles away from home for a postmortem (and thus makes it less likely that the same pathologist is going to see each case/be able to look for a pattern). The coronial system (and the coroner is not a police officer as stated earlier) is looking for the most likely cause of death on the balance of probabilities. In a baby who is known to be sick it is likely that cause of death is related to this +/ their prematurity (and who would suspect murder?). If the doctor is content that they can give a cause of death and the family aren’t wanting an autopsy (for all the reasons mentioned earlier in the great post by @Britneyfan) then I can easily see why one wasn’t carried out. If a baby was found to have pneumonia at postmortem then it’s easy to see how that would be attributed to be the cause of death (pneumonia can cause sudden deterioration and death, especially in the vulnerable e.g. very young and very old). I haven’t read the full details to the cases admittedly but I imagine that the cases that went to autopsy were more likely to be those with deterioration and the babies rather than the babies who were known to be unwell. At least one doctor has mentioned that they regret not being more vocal in pushing for a postmortem but you have to remember that this is a conversation being made at the worst moment of somebody’s life. If you think that, on the balance of probabilities, a baby died of pneumonia then are you really going to force the issue with traumatised and grieving parents?

Re the c-peptide, in a lot of places it’s something that’s added on to a hypoglycaemia screen. Again, not uncommon for babies (especially premature or sick babies) to have low blood sugar. Often they’re isolated events and chasing up the screen is a low priority job (if you’ve not had another hypo and the baby seems to be doing fine etc). It is a bit of more niche medical knowledge, especially as you have to be thinking exogenous insulin administration to get the interpretation (and in a newborn premature baby that would be way down my list of differentials). I can see how it was overlooked. Hindsight is a wonderful thing.

I’m not on the defensive here. I’m sure there were mistakes made by the clinicians which enabled Letby to keep killing. It’s heartbreaking that the c-peptide wasn’t properly escalated. But I’m also sure that all the clinicians involved feel awful for not doing more, for not knowing the relevance of or acting on the c-peptide, for not standing in a police station until somebody agrees to investigate, for not thinking that it was a forensic case at autopsy.

I’m just frustrated that people (understandably to be fair because if you’re not a doctor/know doctors why would you) don’t understand the GMC blame culture and systemic factors at play that impacted on the case. And that people want to hold the doctors, who seem to have done more than many involved to stop the murders, responsible for them. The person responsible for these deaths is Lucy Letby.

Except most of these babies were only* 6-10 weeks premature (I think only one was 25 weeks?) and were described as doing well. One murder/attempted murder even happened on the baby's release day.

In addition to the fact that in June 2015, three babies died which was the same number as the average for a whole year. I've even heard that that was high for the level of unit that it was and they haven't ruled out LL playing a part in any that occurred before June (I think she started in the Feb of that year).

*Obviously compared to those under 30 weeks

Thank you for your posts @Salacia.

There was a Consultant, of South Asian descent, who did try his damndest to have LL looked into but was met with block after block after block.

Here's a timeline of what happened and the concerns raised. The first alarm was raised after the first 3 deaths. If the hospital managers acted then, it could have stopped there. You can't blame the doctors that repeatedly raised concerns and asked for reviews for not doing enough, when the higher ups did nothing.

Murder of Child A
8 June 2015
Child A was born six weeks premature along with his twin sister, Child B, and was days old and healthy when he is handed over to Letby on the night shift. Thirty minutes later he “deteriorates rapidly”. He dies within 90 minutes of Letby coming on duty.
Sex
Boy
Method
IV air embolism
Offence
Attempted murder of Child B
8-11 June 2015
Letby injects Child B with air about 28 hours after murdering the newborn’s twin brother. She survives after being resuscitated. Subsequent tests show loops of gas-filled bowel – a finding later replicated in several babies over the following year.
Sex
Girl
Method
IV air embolism
Offence
Murder of Child C
14 June 2015
Child C was born seven weeks premature weighing 800g (1lb 12oz) but was in good condition. Letby is seen standing over his monitor as his alarm sounded, despite not being his designated nurse. He dies as a result of air being injected into his stomach.
Sex
Boy
Method
Air inserted into stomach (not bloodstream)
Offence
Murder of Child D
22 June 2015
Letby injects air into Child D’s bloodstream, causing her to collapse three times in the early hours of 22 June 2015. Her third collapse is fatal. Those attending noticed discolouration on the baby’s skin.
Sex
Girl
Method
IV air embolism
Alarm raised

2 July 2015
Dr Stephen Brearey, the head consultant on the neonatal unit, carries out a review of the three unusual deaths in June 2015. Alison Kelly, the director of nursing and deputy chief executive, is told that Letby was the only nurse on shift for each of the deaths, the trial was told. Letby remains on the neonatal unit.
Offence
Murder of Child E
4 August 2015
Child E was born seven weeks premature along with his twin brother, Child F, and weighed less than 1.4kg (3lbs). His mother walks in on Letby trying to murder the newborn after arriving on the unit with his milk. He dies after suffering a fatal bleed believed to be the result of Letby interfering with his nasogastric tube.
Sex
Boy
Method
IV air embolism and bleeding from trauma
Offence
Attempted murder of Child F
5 August 2015
Letby laces Child F’s feeding bag with insulin less than 24 hours after murdering his twin brother. A blood sample later confirms “extremely high” insulin levels and very low C-peptide levels – proof he had been injected with insulin.
Sex
Boy
Method
Insulin
Offence
Attempted murder of Child G
7 September 2015
The most premature of all babies in the case, Child G was born 15 weeks early and weighed just over 450g (1lb). Letby tries to kill her three times over three weeks, the first time on the day of her 100th day alive. Child G, now eight, is severely disabled as a result of the attacks.
Sex
Girl
Method
Extra milk and air via nasogastric tube
Offence
Attempted murder of Child G
21 September 2015 (10.15am)
Five days after Child G returned from Arrowe Park hospital, where she had been taken following an earlier attempt to kill her, Letby again tries to take the little girl’s life. This time she is suspected of harming her while feeding her at around 10am.
Sex
Girl
Method
Unknown
Offence
Murder of Child I
23 October 2015
A murder described in court as “persistent, calculated and cold-blooded”, Letby kills Child I on her fourth attempt after inserting air into the baby girl’s stomach. The nurse later sent a sympathy card to Child I’s parents on the day of her funeral.
Sex
Girl
Method
Air inserted into stomach (not bloodstream)
Alarm raised

23 October 2015
Dr Brearey becomes increasingly concerned following the death of Child I. Another staffing review finds Letby was present at more unusual deaths. Another consultant, Dr Ravi Jayaram, alerts management to their concerns but is told “not to make a fuss”. Letby remains on the neonatal unit.
Alarm raised

8 February 2016
A thematic review ordered by Brearey finds several common links in nine unusual deaths since June 2015. Letby’s connection to the mortalities is mentioned at a meeting called to discuss the report, which was sent to the medical director, Ian Harvey. Brearey requests an “urgent” meeting with executives but no meeting takes place until May 2016, the court is told.
Offence
Attempted murder of Child L
9 April 2016
Letby injects insulin into a dextrose bag attached to Child L. Tests later find his insulin level “at the very top of the scale that the equipment was capable of measuring” with very low C-peptide levels – conclusive proof, the prosecution claim, that he was poisoned with insulin.
Sex
Boy
Method
Insulin
Offence
Attempted murder of Child M
9 April 2016
Child M, the twin brother of Child L, suffers an unexpected life-threatening collapse shortly after the insulin poisoning of his brother. His heart rate and breathing dropped dramatically and he came close to death as a result of being injected with air. He survived but suffered brain damage as a result of this attack, the prosecution said.
Sex
Boy
Method
IV air embolism
Alarm raised

11 May 2016
Brearey meets Harvey and Kelly to raise concerns about Letby after an “assurance” document, seen by the Guardian, set out why Letby was not believed to be the cause of the unusual deaths. It suggests other NHS services may be to blame for the spike in deaths and that: “There is no evidence whatsoever against LL [Letby] other than coincidence”. Brearey feels his concerns have been dismissed.
Offence
Attempted murder of Child N
3 June 2016
Letby tries to kill Child N days after he is born. The newborn boy has haemophilia, a condition causing severe bleeding. The crown say Letby uses this as “cover” to attack him by thrusting his nasogastric tube into his throat, causing trauma.
Sex
Boy
Method
Air embolism and thrusting nasogastric tube into throat
Offence
Murder of Child O
23 June 2016
Letby murders the first of two triplets a day after returning from a holiday to Ibiza. Child O had been a “perfect” healthy baby and was due to go home when he collapses unexpectedly. Postmortem X-rays show a higher than normal amount of gas in his body, causing police to believe Letby murdered him by injecting air into his nasogastric tube.
Sex
Boy
Method
Air via nasogastric tube and trauma
Offence
Murder of Child P
24 June 2016
Shortly after killing Child O, Letby turns to his days-old triplet brother. The nurse pumps air into the boy’s stomach via his nasogastric tube while feeding him milk at 6pm, 13 minutes after his brother had died. Experts believe this excess air shattered the little boy’s diaphragm. Doctors believe he will make a full recovery but, as they ready him for another hospital, Letby says: “He’s not leaving here alive is he?” She had made a similar remark when Child C fatally collapsed a year earlier.
Sex
Boy
Method
Air via nasogastric tube
Alarm raised

24 June 2016
The “tipping point” comes following the unexpected deaths of Child O and Child P. Brearey phones the duty executive, Karen Rees, on the evening of Friday 24 June 2016 to say Letby has to be removed from the unit. Rees insists Letby is safe to work and is happy to take responsibility if anything happened to other babies when Letby was involved, the trial was told.

Yes, I honestly think they would have when presented with the facts from seven senior doctors.