Residents called Lucy Letby “Nurse Death,” investigation found

Junior doctors have dubbed Lucy Letby “Nurse Death,” a public inquiry has revealed.

During the Thirlwall Inquiry, which was set up to examine the British health service's response to the serial killer, it was revealed that the chief nurse of an inquiry into the increase in infant mortality told paediatricians that Letby was the “common denominator”.

Nicholas de la Poer KC, the lawyer leading the inquiry, also told the hearing that Letby had attempted to murder one of the babies during a hospital inspection.

The 34-year-old was convicted of the murder of seven babies and the attempted murder of seven more babies at the Countess of Chester Hospital between June 2015 and June 2016.

According to the investigation, Ian Harvey, the trust's medical director, raised his concerns about Letby in an interview with an external review team in September 2016.

Notes from his interview shared at the hearing said pediatricians viewed Letby as the “elephant in the room.”

Mr Harvey also noted that he “had to intervene with the head of the neonatal unit because the junior doctors had referred to her as 'Nurse Death.'”

His notes continue: “The team is worried and trying to function. I don't know how to end this without calling the police.”

“If there is nothing that satisfies the medical staff, they can call the police.”

Mr de la Poer told the committee that when asked what the “turning point” would be before reporting the matter to the police, Mr Harvey had also replied: “We need to pull together before we push the nuclear button.”

Chief nursing officer Alison Kelly told the inquest that paediatricians believed Letby was the “common denominator” and added that there were no issues with her competency.

She also said: “Doctors threatened to go to the police.”

The investigation found that Cheshire Police were not contacted until May 2017 and the trust failed to refer the case to other regulators, including the Nursing and Midwifery Council.

The Trust discussed the matter informally with a senior Cheshire Police officer at a meeting on 27 April 2017.

Det Ch Supt Nigel Wenham, of Cheshire Police, told the inquest that the phrase “angel of death” was used at the meeting to describe Letby.

On 2 May that year, he briefed senior officers of Cheshire Police and the force planned to receive a letter from the hospital formally requesting them to investigate the unexplained deaths in the neonatal unit.

Even afterwards, Harvey told NHS England that neonatal unit doctors had influenced police by sending a letter “which gave a very biased view and essentially pointed the finger at a nurse.”

He stated that he had a “feeling” that there would be no investigation unless the doctors reported something “new.”

He added that he believed the police would stand by the trust “with a message that will enable us to put an end to the speculation here and deal with the cultural issues.”

In fact, on May 17, 2017, the consultants met with police and explained in detail why they considered the deaths suspicious.

Mr de la Poer said Det Ch Supt Wenham described the meeting as a “critical and important event”.

In the afternoon, Cheshire Police concluded that there were sufficient grounds to suspect a criminal offence and launched a criminal investigation.

Mr de la Poer also discussed the role of the health regulator, the Care Quality Commission (CQC), which inspected the hospital on the same day that Letby attempted to kill a baby.

Letby was found guilty of attempted murder of the child, referred to in court as Baby K, by disconnecting her breathing tube and leaving her to fend for herself in her deteriorating condition in March 2016.

Mr de la Poer said the neonatal unit's chief medical officer, Dr Stephen Brearey, had said inspectors had “failed to address neonatal mortality”.

He said one of his colleagues told them that staff had “serious concerns about patient safety and did not feel they were being listened to,” but he was ignored.

The inspectors left before there was time to address the concerns in more detail, Mr de la Poer added.

During the investigation, it emerged that one of the CQC inspectors, Elizabeth Childs, could not recall any discussion of the increased, unexpected or unexplained number of newborn deaths taking place during the inspection.

The hearing also pointed out that regional hospital managers had failed to notice a significant increase in the number of babies dying at Countess of Chester.

The clinicians were not aware that there was a “glaring” difference in the infant mortality data, de la Poer explained during the investigation.

A steering group of the Cheshire and Merseyside Neonatal Network was presented with statistics in January 2016 showing that the number of baby deaths had risen from three in one year to eight in nine months between 2014 and 2015, he said.

However, it was not until July of that year that concerns about the increased number of baby deaths were added to the Trust's emergency care risk register.

However, the risk was assessed as a “potential reputational risk” to the department and hospital, rather than a risk to the safety of babies on that unit.