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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.