After serial killer Lucy Letby was found guilty of killing newborns under her care, a top patient safety investigator emphasised the “tragic” results of hospital management “protecting reputations” above paying attention to worker complaints.
As baby killer Letby carried out a year-long killing spree at the Countess of Chester Hospital, numerous employees voiced their worries about her behaviour.
The 33-year-old nurse was found guilty of killing seven infants and trying to kill six more while working on the neonatal ward between 2015 and 2016.
The Countess of Chester Hospital is facing increasing criticism for the nurse’s prolonged stay in the neonatal unit.
Dr. Bill Kirkup claimed there were “common features” between the circumstances surrounding the death of Lucy Letby and investigations he has performed into subpar maternity care in other hospitals.
Additionally, a doctor and MP deemed it “remarkable” that staff members’ complaints went unheeded.
It comes as police announced they are looking into the treatment of 4,000 infants who were treated to the Countess of Chester and Liverpool Women’s Hospital between 2012 and 2016, during which time Letby had two work placements.
A further investigation into the circumstances behind the murders and attempted murders has also been authorised by the government.
Dr Kirkup, who led the reviews into poor care in maternity units in Morecambe Bay and East Kent, told BBC Breakfast: “I think there are a number of common features that underpin a lot of these different investigations and ring bells with what I’ve been hearing about what happened in the Countess of Chester Hospital, particularly the difficulty in persuading people that there’s a real problem here that must be investigated and must be looked at properly and independently.
“And particularly the chasm that can open up between clinicians who are reporting problems and managers who don’t necessarily want to hear.”
He added: “I heard yesterday for the first time in this connection, the phrase ‘protecting reputation’ on the part of the Trust and that rings a massive bell for me because that’s been a feature of everything that I’ve been involved with for the last 12 years or so.
“The first reaction of people under these circumstances in management, controlling organisations, is to protect reputations – the organisation’s reputation, their own reputation.
“And when that comes ahead of being open and honest about what’s going on, that’s tragic. We have to be able to stop this.”
The relatives of her victims have indicated that they are “heartbroken, devastated, angry and feel numb” as a result of her crimes.
But since the serial killer has said she won’t attend the hearing at Manchester Crown Court, it’s believed they won’t see Letby when she is sentenced on Monday.
Lawyers for some of the families have vowed to keep looking for solutions.
The management of the Countess of Chester Hospital, according to MP and paediatrician Dr. Caroline Johnson, is “completely unacceptable” for failing to respond promptly to concerns raised by specialists.
“To my mind, as it has been reported, it is completely unacceptable,” the Conservative MP told BBC Radio 4’s Today programme.
“When you’ve got seven paediatricians, experts in their field, looking after babies in a neonatal unit telling you in their expert opinion that these events are unusual and they should not be occurring and there are unexpected collapses that are unexplained in babies that are leading to death, to then say you are not going to take action seems completely remarkable to me.”
Dr Kirkup said that the independent inquiry will give families a “chance to be heard”.
“I think the families who have suffered this unimaginable harm, need a chance to be heard, I think that the people involved at the hospital need the chance to be heard,” he said.
“Secondly, it does allow you to find out, usually very rapidly, what exactly the underlying problems were.”
The nurse was on duty for each of the 13 deaths that occurred on the neonatal unit where Letby worked over the course of a year, which is five times the typical rate.
She might have been stopped as early as June 2015, when executives met and decided to hold an outside probe into the killings, but it never happened, according to the broadcaster.
Seven infant deaths later, in October of that same year, a connection was discovered between all of the fatal collapses and Letby, whom the prosecution referred to be a “constant malevolent presence” in charge of the children.
Despite this, it was thought that the connection was coincidental.
Dr Susan Gilby, who took over as the hospital’s medical director a month after Letby was arrested, told the BBC: “The paediatricians were discussing the terrible nights on call that they were having, one of them said ‘every time that this is happening to me, that I am being called in for these catastrophic events which were unexpected and unexplained, Lucy Letby is there, and then somebody else said ‘yes I found that’, and then someone else had the same response.”
According to paediatrician Dr. Stephen Brearey, who exposed Letby in 2015, the hospital handled the killings in a “negligent” manner.
The Royal College of Paediatrics and Child Health was contacted in September 2016 to conduct an assessment of the facility after consultants requested to contact the police but no officers were dispatched, according to the BBC.
It asked the trust to look into each death separately, however it has been stated that this did not happen.
The paediatricians were ordered to write the murdering nurse an apology letter after she filed a grievance against them alleging that they had “discriminated against and victimised” her.
After the deaths of two triplet boys that month, she was later removed from the newborn ICU.
On July 3, 2018, around six in the morning, she was taken into custody at her semi-detached Chester home in Westbourne Road while she was still employed by the trust.
Several handwritten notes were found at her address while searches were being conducted there.
On one green Post-it note, she wrote “I don’t deserve to live. I killed them on purpose because I’m not good enough to care for them”, “I am a horrible evil person” and in capital letters “I am evil I did this”.
Speaking to the BBC, Dr Gilby said of that time: “The strong opinion was that there would be nothing found.
“There was a brief overlap of three or four days between myself and the outgoing medical director, and his parting words to me were ‘you need to refer the paediatricians to the General Medical Council’.”
Tony Chambers, the former chief executive of the Countess of Chester Hospital NHS Foundation Trust, declared that he would cooperate “fully and openly” with the investigation.
Dr Nigel Scawn, medical director at the Countess of Chester Hospital, said in a statement on Friday: “Since Lucy Letby worked at our hospital, we have made significant changes to our services and I want to provide reassurance to every patient that may access our services that they can have confidence in the care that they will receive.”
But he walked away without answering as a journalist asked: “Why did hospital managers try to stop Lucy Letby from being investigated?”