‘Lucy Letby: The Thirlwall Inquiry and the Truth About the Countess of Chester Neonatal Deaths Scandal’

When the Thirlwall Inquiry into the circumstances that allowed for a cluster of neonatal deaths to occur at the Countess of Chester between 2015-2016 began on 10 September, Lady Justice Thirlwall was at pains to point out that it would not explore the question of whether or not Lucy Letby had harmed any of the babies involved.

In August 2023, Letby, 34, was convicted of seven counts each of murder and attempted murder, and sentenced to life imprisonment with a whole life order.

Thirlwall went on to describe as “noise” the increasing body of concern being expressed at the verdicts of murder by a wide range of senior academics, clinicians and scientists, 24 of whom wrote to the Criminal Appeal Office of the Royal Courts of Justice, pointing out that the Inquiry as currently framed was predicated on the guilty verdicts so would preclude a full understanding of why the Countess of Chester had performed so badly and whether other factors other than a malicious nurse could have been responsible for the deaths.

The request was denied during the first days of the Inquiry, with both the Chair and the supporting King’s Counsel, Rachel Langdale, suggesting the concerns were part of a narrow conspiracy of statisticians who had not been present at the original trials (Letby has another appeal next month).

In reality, the 24, together with many more people of good professional standing, included authorities not only in statistics but also neonatal and other relevant branches of medicine, including epidemiology and public health, a range of pertinent sciences including the engineering aspects of the equipment used in neonatal units, and those with experience of throwing light on previous miscarriages of justice.

Between them, they had extensive  experience of researching and evaluating evidence, that included the documentation of the trials but also the scientific criteria for evaluating cause and effect links in the field of biological medicine, criminology, and the social sciences.

For counsel to the Inquiry to describe them as “conspiracy  theorists”, was not only offensive but placed at risk the reputation of the good standing of the judicial process and was in contrast to the willingness of Judge Goss, in the original trial, to allow as an ‘expert witness’, retired paediatrician, Dewi Evans, who was described in a previous trial as somebody who could not be accepted as being credible in that role. 

As for the claim that those concerned about the reliability of the verdicts had not been at the trials – quite apart from the difficulties put in the way of those researching the detail, for example by demanding a fee of £100,000 for access to the transcripts – the highly experienced and credible but uncalled expert witness for the defence, neonatal medicine consultant, Dr Mike Hall, who has gone on the record as challenging much of the clinical argument for Letby’s guilt, was present for both.

Lady Justice Thirlwell was not. 

I am an experienced and senior public health doctor who was centrally involved in many serious clinical service failures including the Alder Hey Childrens Hospital organ retention scandal, the Morecambe Bay Hospitals infant deaths scandal, and the  Cumberland Infirmary breast screening service scandal, together with multiple instances of delinquent medical practice, and the aftermath of the Shipman serial murders of patients.

These clinical service failures have much in common with other large-scale disasters, such as the Kings Cross fire, the Piper Alpha and Herald of Free Enterprise tragedies, Hillsborough, and Grenfell Tower disasters, because that is what they are.

What they have in common is what has been described as the ‘Gruyère Cheese’ phenomenon, whereby all the risk factor holes are lined up and as a result, in retrospect, something was inevitably going to happen. 

In the case of the Countess of Chester Hospital, the backcloth was a rush to become a Foundation Hospital in the early noughties, with its promise of freedom from national control and appeal to the hubris of aspiring to provide specialist services beyond its expertise in competition with other hospitals; a constrained financial environment compatible with such ambitions; and the recurring phenomenon of senior clinical and managerial leadership unwilling to listen to the concerns of frontline staff further down the food chain, as described by former Chief Medical Officer, Liam Donaldson, in his major report ‘Organisation with a Memory’ 20 years ago. 

A true understanding of the causes of the cluster of deaths at the Countess of Chester requires an open mind and a 360-degree understanding of the role of all players at an individual and organisational level, including the proper functioning of those relationships with a range of outside bodies.

After sitting through the comprehensive scene-setting at the Inquiry by the King’s Counsel  it is as clear that at the point when Letby was prevented from working as a nurse, later in 2017, the only evidence against her was that she was ‘working when she was working’ and that this was when some of the serious incidents involving low birth weight, premature, and at-risk babies took place.

Since then the Sunday Telegraph has reported that the original statistical chart of who was on shift and when, was doctored to exclude one doctor and one nurse who were also working at the same time as Letby, leaving her in the headlights of potentially a real conspiracy and one of the worst miscarriages of justice yet known. 

A damning report into the Countess of Chester neonatal unit in 2016 by the Royal College of Paediatrics and Child Health produced an extensive list of the weaknesses of the unit that amounts to a dysfunctional and dangerous neo-natal service. The team that produced that report pulled its punches and the report never really featured in the trials.

Behind the scenes, nurses at the unit and Letby herself talk of a bullying culture and there are indications that some of the consultants decided, without any concrete evidence, that a highly regarded and dedicated young nurse had turned overnight into a serial killer rather than holding up the mirror to their own roles in providing a safe service.

On day two of the Inquiry, Kings Counsel Rachel Langdale rehearsed one by one the post mortem, coroner and other pathological details of the babies who Letby was supposed to have murdered.

Each was accepted as being down to a natural indeterminate cause, some with evidence of infection or septicaemia, possibly brought with them from the maternity unit, which was experiencing serious untoward incidents, and no suggestion of any suspicious factors.  

In understanding what happened at the Countess of Chester in 2015-2016, the holes in the Gruyère cheese were all perfectly aligned and there was no need of a murderer to explain the tragedies to the parents.

It would take the maverick ‘expert witness’ Dewi Evans to provide allegations involving the injection of insulin, of air to form emboli, and of brute force, to explain how Letby became a frenetic killer. 

Evans championing of the idea of ‘Munchausen by Proxy‘ in which a care giver is held to seek attention through the faked sickness of another bears further examination in view of the claimed role of the anonymous registrar ‘DR A’, who seems to have held a torch for Letby but whom the prosecution claimed was the victim of her attention seeking behaviour, “harming the babies so he would turn up on the ward and she could be with him”.

Each of the explanations of how Lucy is held to have harmed infants is now being challenged by the 24 experts, together with many more reputable voices.

As to the ‘Munchausen by Proxy ‘ and the supposed “infatuation of Lucy with the anonymous DR A”, surely transparent truth and justice demand that this too be properly explored. 

It is now not only Letby’s life under the hammer but the credibility of the British Justice System.

Evans, whilst using statistics himself, decries the proper use of them by those qualified to do so. Now is the time to go beyond the prosecution ‘facts’ and get to the truth.