Lucy Letby inquiry: Rise in baby deaths was ‘inevitable’ in unit, hospital bosses warned

A spike in deaths at Lucy Letby’s hospital was “inevitable” because of the “acuity and busyness” of the unit, managers believed.
The Thirlwall Inquiry heard how executives at the Countess of Chester held a meeting with doctors in the summer of 2016 and showed a graph which linked the rise in mortality to patient numbers.
Dr Susie Holt, who joined the hospital as a consultant in April 2016, told the hearing how she was called to a meeting to discuss the increased deaths.
“We were being told of the rise of acuity and busyness on the unit, that perhaps an increased number of deaths was inevitable,” she said.
“I’m not sure what role statistics have to play in this situation. The death of each and every baby needed to be scrutinised to understand whether they were sudden, whether they were unexpected.
“I think the individual patients were what was important and the matters around what happened to each of them rather than arbitrary statistics like the number of days between deaths.”
The Thirlwall Inquiry is investigating how the deaths and collapses at the Countess of Chester were allowed to continue for so long.
Consultants had complained to managers about the spike in mortality in 2015 and had warned that Letby was present at all the incidents.
Dr Elizabeth Newby, a Consultant Paediatrician who worked at the neonatal unit in 2015, told the hearing that initially there had been an ‘air of disbelief’ that Letby was harming babies.
“No one had ever seen anything happen,” she told the inquiry. “It was just a feeling that she was always there. At the time there didn’t appear to be any evidence.
“There was an air of disbelief about it. The only thing that we could say at the time was that she happened to be on all of the shifts. No one had ever seen anything, heard anything, there were lots of counterarguments, that she was a very competent nurse, everyone observed good practice.
“We were a very small unit, with a very small pool of nursing staff so it was not inconceivable that the same poor person might have been on duty for a number of events.”
The inquiry heard how the doctors initially believed that a medical or environmental reason might be responsible for the increased death rate. Dr Holt said that superbugs and medication side effects had all been considered in a mortality review in April 2016.
Dr Rachel Langdale KC, counsel for the inquiry asked if the medical causes had been “investigated and eliminated”.
Dr Holt said it was “difficult to eliminate them” but they had been investigated and some guidance and treatment plans had been changed following the mortality review.
Consultant Dr Murthy Saladi said he was initially concerned that the baby deaths and collapses were due to an outbreak of the lethal bacteria pseudomonas in the unit.
“For all the taps in the unit we had filters and they were growing pseudomonas from the taps,” he said, although he said the team was never able to find evidence of an infection in the babies.
Dr Saladi said that by January 2017, the relationship between consultants and managers at the Countess of Chester had broken down.
He described a meeting in that month in which Tony Chambers, the chief executive, had “banged the table” and told the consultants that the hospital was “drawing a line under” the allegations.
“I do remember the red face of Tony Chambers, his forceful voice and him banging on the table,” Dr Saladi said in a statement to the inquiry.
Dr Saladi said he would “carry the guilt” of not being able to prevent the baby deaths at the Countess of Chester for the rest of his life.
In a closing statement, he told the parents that he was “profoundly sorry”.
“It is a guilty feeling I carry and I think I will carry for the rest of my life. I am profoundly sorry for that.”
The inquiry has now finished for the week and will return at 10am on Monday when it will hear from further consultants.
Dr Holt said she was angry about the way the neonatal unit was described in a Royal College of Paediatrics and Child Health report in 2016.
The report described multiple failings in the unit, highlighting understaffing, gaps in rotas, poor decision making, delays in seeking advice, and delays in taking babies to regional hospitals.
Dr Holt said: “[I’m] angry that we were represented in that way because I don’t think it’s a fair reflection on the service that we were providing.”
Earlier she said: “We were providing an amazing service to paediatric patients and training the next generation of doctors.”
Asked why she hadn’t gone to the police earlier she said: “I don’t know why we didn’t. It is a huge regret. I wish I had done something back in 2016.”
Dr Holt said she had not referred the issue with the Local Authority Designated Officer because the evidence was circumstantial.
“From a personal point of view it was the overall situation, it was the number of unexplained incidents that was such a concern and there wasn’t ever one individual case where I thought that needs referral,” she added.
Dr Holt told the inquiry she was “devastated” to be asked to write a letter of apology to Lucy Letby after the nurse won a grievance in January 2017.
She said: “I didn’t feel it was appropriate. I didn’t feel I had a choice and I am quite embarrassed that we ever wrote that letter and sent it. I don’t know how it makes the families feel to see that and have read that. I think it’s awful.”
Dr Holt said that many of the nurses continued to support Letby despite the allegations and she was invited to a Christmas party in December 2016, even though she was still banned from the unit.
She said: “There was so much swirling. We now know that she has been tested in a court of law and found guilty, but at that time we were still dealing with uncertainty. Can this possibly be true?
“It was a pretty astonishing time. We all felt that working with our board was going to be better than ending up on gardening leave which felt like was the insinuation from that January meeting.
“That if we didn’t toe the line then we wouldn’t be remaining in our jobs. 
“It’s important to remember at this point there is already talk of her returning to the neonatal unit. So there was a degree of thinking actually we need to keep our voice and not be silenced.”
Dr Holt said she told managers in June 2016 that she would not want her friends treated at the Countess of Chester while Lucy Letby was still working on the unit. 
“I was really concerned, and wouldn’t have wanted that care for my friends,” she said. “It didn’t feel safe with the current uninvestigated concerns. 
“We had some medical explanation in part for some of the deaths, but as a cohort when you looked at it all together, there was something happening and we were aware of this uncomfortable association with one particular team member.
“What human wants to hurt any living creature and then to hurt a defenceless baby to hurt the families, it’s abhorrent in society to think of people intentionally inflicting harm.”
A spike in deaths at the Countess of Chester was “inevitable” because of the “acuity and busyness” in the unit, managers told consultants. 
The inquiry heard how management held a meeting in July 2016 and showed a graph, linking the rise in mortality to patient numbers. 
Dr Holt said: “I remember the message we were being given, which I couldn’t corroborate. 
“We were being told the rise of acuity and busyness on the unit, that perhaps an increased number of deaths was inevitable. 
“I’m not sure what role statistics have to play in this situation. The death of each and every baby needed to be scrutinised to understand whether they were sudden, whether they were unexpected. 
“I think the individual patients were what was important and the matters around what happened to each of them rather than an arbitrary statistics like number of days between deaths.”
Later in the inquiry she added: “It’s really important that we did consider all factors, so it wasn’t to be instantly dismissed, it did need thought and consideration because if that had been a contributing factor you would want to take steps to remediate that.”
Dr Holt said she had seen a mortality report in April 2016 which had investigated deaths at the Countess of Chester.
“You’re first thought are always about medial causes, because that’s my training,” she said.
“They thought about superbugs and common medications and side effects.”
Dr Rachel Langdale KC said: “And it investigated and eliminated them?”
Dr Holt said: “Difficult to eliminate them but investigated them and then thought about ways and means of modifying the sort of guidance going forward, the treatment plans etc.”
Dr Suzy Holt told the inquiry she regretted not going to the police in June 2016 after learning of a string of deaths on the unit.
Dr Holt started working as a consultant at the hospital in March 2016 and was unaware there had been several unexplained deaths and collapses.
She told the inquiry she had been copied into an email from Dr Murthy Saladi calling for a police investigation. 
“If I could change one thing in my life I would have called the police that day,” she said in a statement to the inquiry. 
Dr Saladi said he would “carry the guilt” of not being able to prevent the baby deaths at the Countess of Chester for the rest of his life.
In a closing statement he told the parents that he was “profoundly sorry”.
He said: “I want to apologise to all parents for not being able to prevent the deaths and the harm done.
“It is a guilty feeling I carry and I think I will carry for the rest of my life. I am profoundly sorry for that.”
Dr Saladi said he had not told an inquest that Letby may have been responsible for the death of Child A because he was never asked. 
Nicholas de la Poer KC, counsel for the inquiry, pointed out that by the time of the inquest in the autumn of 2016, consultants had already raised concerns about Letby and had discussed the possibility of air embolism.
Yet none of the consultants told the coroner that there were suspicions that a member of staff was deliberately harming babies. 
Dr Saladi said he was “stressed” and had been told to keep his answers brief. 
“It is probably in retrospect a mistake for me to not share my concerns, but that is because of inexperience I think,” he told the inquiry.
“I think that was probably my first appearance at an inquest and I was stressed and the advice we got from the solicitors was answer the questions, don’t answer what you think was asked and keep it brief and do not speculate.”
Dr Saladi said that by January 2017, the relationship between consultants and managers at the Countess of Chester had broken down.
He described a meeting in that month in which chief executive Tony Chambers had “banged the table” and told the consultants that the hospital was “drawing a line under” the allegations. 
“I do remember the red face of Tony Chambers, his forceful voice and him banging on the table,” Dr Saladi said in a statement to the inquiry.
Dr Saladi said he was asked to write a letter of apology to Letby.
After the meeting the consultants said they had written further emails to the management asking for the deaths to be investigated and had considered going to the media.
Dr Saladi said paediatricians would only expect to see an unexplained baby death at a district hospital “a couple of times” in their career.
But he said he found it “difficult to swallow” that somebody would be blamed for harming babies just because they were on duty at the time. 
He said: “I was thinking of my own time when I came to the UK, because I trained in India and when I first came to the UK I was attending all the sick children because I wanted to know how things are different. 
“So to blame somebody because they were there was difficult for me to swallow at that stage.”
Dr Saladi said that looking at the rota did not show “definitively” who was on the ward because doctors and nurses from the paediatric units could also come and go into the neonatal unit. 
He said: “I worked with Lucy and she appeared as a competent nurse so I did not have any direct worry or suspicion on her.”
Dr Saladi said that he felt that an independent investigation should have taken place followed by contacting the police if there was evidence, because he feared that internal inquiries were “coming across as doctors versus nurses”.
Dr Saladi said he feared that the parents of Baby N were going to report him to the General Medical Council for the substandard care of their child.
The little boy needed to be resuscitated after collapsing unexpectedly on June 15 2016 and Dr Saladi said the team had struggled to “secure the airway” of the baby. 
Dr Saladi said his mouth was dry and he could not answer the parent’s questions about the collapse. 
“They didn’t say anything about the GMC but I thought they were unhappy with the care provided,” he said. “I do not remember the exact words, but I think they said ‘you have provided substandard care.’”
Dr Saladi said babies would deteriorate at the Countess of Chester and be sent to other units and get better. 
He told the inquiry that he thought “are we missing something?” but said the focus was looking for a medical explanation for the sudden collapse and deaths.
“We were seeing the babies with abdomen distention and we are sending them to the regional units and they are coming back because they are not finding anything,” he told the inquiry.
“So I suspect that I should have raised concerns. We were scratching our heads. I don’t think we connected with all the other previous deaths. I was thinking that we are going through a bad patch.”
Dr Saladi said he was concerned that the baby deaths and collapses at the Countess of Chester were due to an outbreak of pseudomonas in the unit.
He said: “For all the taps in the unit we had filters and they were growing pseudomonas from the taps.
“We were thinking it was related to the taps, and tings like that”.
Risk reports previously leaked to the Telegraph showed that the bacterium pseudomonas aeruginosa had colonised taps in the nurseries of the neonatal unit, including intensive care during 2015 and 2016.
He added: “Having a few deaths grouped together, it’s not unusual, and usually…it is some sort of bug or something like that. 
“We know that in the neonatal unit deaths can happen particularly is there is any outbreak infection, so there can be grouping of the deaths so I was thinking this is all related.
“I thought ‘are we missing some bug, something else that was happening, that is why we were having this bad bad phase with more deaths?’”
Nicholas de la Poer KC, counsel for the inquiry said: “None of the investigations came back to say that was the explanation for the cluster did they?”
“That is correct,” said Dr Murthy. 
Dr Murthy Saladi, a consultant paediatrician, told the hearing that he initially thought the death of Child A may have been related to a “maternal health condition”.
Dr Saladi was present for the birth of twins Child A and Child B in June 2015.
Doctors had noticed a rash on the babies and Dr Saladi said the team had tried to contact specialists in London to find out if the death and collapse may have been because of the mother’s health.
The mother of the twins had an auto-immue disease which can increase the incidents of blood clots. 
“I did not think the rash I had seen was serious,” he told the inquiry. “The rash I had seen based on what was documented in the ward rounds, did not sound very serious. 
“There are lots of causes for the rash, some rashes can happen in the newborn period.”
Letby is convicted of murdering Child A and attempting to murder Child B with an air embolism. 
The inquiry is now taking a break and will resume at 11.30am when it will hear evidence from consultant Dr Murthy Saladi.
Dr Newby, who is now a clinical director at a different hospital, said that nobody saw Letby harming babies but there was a “feeling” she was always there.
However she accepted she had not raised concerns when the Care Quality Commission (CQC) inspected the hospital in February 2016.
Dr Newby said she had backed consultants Dr Stephen Brearey and Dr Ravi Jayaram when they raised their concerns that Letby could be responsible.
“What was happening on the neonatal unit was not normal,” she said: “Everything needed to be considered, so I backed Dr Brearey and Dr Jayaram in raising concerns. I didn’t raise these concerns personally. 
“No one had ever seen anything happen. It was just a feeling that she was always there.
“A person being put forward led to this counter narrative that it couldn’t possibly be her because she was so lovely, she was a competent nurse, so it became almost an adversarial thing that the doctors were accusing the nurses and everyone was digging in their position.
“At the time there didn’t appear to be any evidence.”
Doctors were in “disbelief” that Lucy Letby could have been harming babies.
Dr Newby said doctors in the neonatal unit were not convinced Lucy Letby could be harming babies.
She said: “There was an air of disbelief about it. The only thing that we could say at the time was that she happened to be on all of the shifts.
“No one had ever seen anything, heard anything, there were lots of counter arguments, that she was a very competent nurse, everyone observed good practice.”
Dr Newby added: “I did struggle with the idea that somebody was doing this.”
The inquiry heard how doctors called a meeting following the death of Child I in October 2015 and concerns were raised about Letby. 
However Dr Newby said there were also counter arguments to Letby being responsible.
She added: “We were a very small unit, with a very small pool of nursing staff so it was not inconceivable that the same poor person might have been on duty for a number of events. 
“I felt the idea that anyone was suggesting that someone was doing this quite difficult.”
Dr Newby said it was “often the case” that blood test results would not show if a newborn baby had sepsis.
Earlier in the inquiry, the mother of Baby D had said that Dr Newby told her test results indicated the infant did not have an infection.
“I do definitely remember meeting with the parents,” she said. 
“I would have been explaining about blood culture results and that although we felt that she did have an infection and was septic and presented that way, the blood cultures hadn’t proven that but that is something that is often the case in neonates.
“A medical model of sepsis seemed reasonable and appropriate.”
Nicholas de la Poer, Counsel for the Inquiry asked Dr Newby: “Were you, at that stage, suspicious that any of the deaths were unnatural?”
“No,” she said. 
Doctors suspected a “bug” was causing deaths and collapses on the ward where Lucy Letby worked, an inquiry heard.
Dr Elizabeth Newby, who worked on the neonatal unit at the Countess of Chester hospital, said she was worried there may have been a “bug” on the ward, or contaminated equipment causing the deaths and collapses of infants.
Doctors had noted a “strange purpuric rash” on several babies who had collapsed and died in the unit in June of 2015.
Dr Newby told the inquiry that doctors had “spent a lot of time” discussing what could have caused the “strange colour change” in the infants.
She said: “I knew that the trainees were very concerned about it. Each baby had appeared to be infected, perhaps septic. 
“We were concerned that we had a bug on the unit, maybe contamination of some equipment, one of the ventilators for example, so we were extremely concerned about it.”
Dr Elizabeth Newby, Consultant Paediatrician at the Countess of Chester Hospital, is giving evidence of the death of Child D, a little girl who died just two days after birth in June 2015.
Dr Newby said she originally thought the death was most likely from sepsis but contacted the coroner for a postmortem to find out what had happened. 
She said: “I felt at the time the correct course of action was to phone the coroner and discuss the unexpected death with the coroner. 
“Although it was very unexpected, I was working within a medical model, there was evidence of sepsis and, although it was unexpected, she had been unwell and therefore I discussed that with the coroner and I thought I was working within that model rather than it was in a completely unexpected and unexplained death.”
The Thirlwall Inquiry is continuing today and hearing from consultants who worked at the Countess of Chester Hospital in 2015 and 2016 at the same time as Lucy Letby.
Dr Elizabeth Newby, consultant paediatrician, will be kicking off proceedings, followed by Dr Murthy Saladi and Dr Suzy Holt.