LL Part 26: Hospital policy was to treat all the babies as if they had severe infection

When exactly can we start calling it corporate collusion, malfeasance and a cover-up?

Following on from the previous part in our Letby series here.

The big news over the last 48 hours has been the leaked report from Countess of Chester Hospital (CoCH) evidencing the lethal bacterial outbreak that was ongoing during the period when it is claimed Lucy Letby went on a baby murdering spree. The article, written by Sarah Knapton and published in The Telegraph¹, discusses details of the report and the effect that Pseudomonas Aeruginosa would have had on these critically compromised premature neonates.

Someone asked me directly this morning why it is that I was not more surprised. After taking advice I can give that person, and all of you, my response.

Sadly, I was here first

In June 2023 I was contacted online by someone I knew who told me they had access to both the report and the modified care policy that is also discussed in Sarah’s article. Over a zoom call that person told me the first post in my series on the first Letby trial (found here) was on the money, and was able to show me the report and treatment guideline were, at that time, still accessible on the CoCH Intranet. We discussed what they should do with this knowledge and how it presented a number of problems.

First, on a moral and ethical level, here was information that directly contradicted the testimonial record of Lucy’s first trial. This was what in legal terms might be considered exculpatory evidence - evidence that is favourable to the defendant because it tends to either (a) disprove the prosecution’s; or (b) support the defendant’s, version of events. Unlike the prosecution evidence, none of which was inculpatory² and all of which was circumstantial and required leaps of logic and inference in order to find guilt, this report and the clinical guideline (treatment protocol) tended to exonerate Lucy by, in corroboration with the clinical evidence I describe in my various articles on each neonate, completely explaining away how and why the neonates became unwell and in some cases, died. While almost every prosecution witness had denied infection was an issue and claimed these premature and unwell neonates were stable and doing well, here was a report that clearly spoke to the management and senior medical staff’s knowledge that a deadly infective agent had taken hold in several critical areas of the hospital, including the neonatal unit. Coming forward might have placed these documents in the public eye, but done so either at a time when most were unwilling to see what they had to say, or when they might have simply gotten lost in the noise or been easier to wave away and disregard.

Second, coming forward at that time would have almost certainly painted a target on this person. While we are supposed to have protections for whistleblowers (Public Interest Disclosure Act 1998), this rather haphazardly applied legislation is of little comfort when you are dismissed (either for cause or constructively) and fighting for your rights from a position of no job and no income to keep a roof over your head, pay the bills and feed yourself or a family. Recent cases like that of Kong v Gulf Bank International (UK)³ show that whistleblower protections are often not worth the paper they are written on. The court found that employers can still dismiss you if they can claim your conduct is considered by them, the employer, to be disagreeable. Let’s face it, if you are questioning key staff of the employer as to their knowledge or culpability in potential illegality in a situation like this, or leaking key evidence of their culpability to the authorities, what employer won’t stand up to say they find your conduct disagreeable? In a more closely related case, Kumar v Care Quality Commission⁴, a Doctor was intimidated after he reported issues within the hospital that included inadequate inspections, staff bullying and serious patient harm. Dr Kumar raised concerns about the poor quality care provided by another doctor that was being overlooked or potentially covered up by management, but in return was subject to intimidation and claims of being racist. Dr Kumar was suspended and while the tribunal went to great pains to warn employers that suspending or constructively dismissing employees for making protected disclosures can be detrimental to the whistleblower. Again, sadly, this is of little comfort when you are a year or two into unemployment, and even if you are given your job back, who says the environment you return to will be one you feel comfortable or want to be in? In this case, my contact could potentially be exposed to protracted prosecution for accessing and sharing documents Trust management might say are confidential or seek to claim privelege over, they could be considered unemployable elsewhere in the NHS as other Trusts might not want to employ someone who exposed the dirty secrets of their former Trust employer, and they could loose their home, partner, children and entire life for doing something they felt was morally right.

At the time I also counselled them not to print the documents - that while accessing them may have already left an indelible record in the computers for someone to find, my experience in other Trusts had seen that printing them on Trust printers might trigger even more records in other systems. We agreed at the time that I could use what I had learned but that I would do so in a manner that was embedded in, and confirmatory to, what I was already discovering. They decided based on our discussion and the precarious nature of their own position that it was best not to ‘go public’. I agreed with this assessment.

About six weeks ago Richard Gill told me he was aware that there may be another whistleblower at CoCH. As with my situation, he was told there may be a document that revealed management were aware of a bacterial outbreak, and that this person may have been willing to provide the report anonymously but if they did, it was going to be to an entirely different journalist at a different newspaper. However, beyond that, Richard’s knowledge was limited. I don’t believe Richard had seen the report or knew specifically of any of its contents. Until then, I had been unaware there was anyone else outside the senior management and medical officers at CoCH that had seen or was willing to expose the document and, due to the promise I had made to the person I had spoken to, Richard remained unaware of my knowledge of the report. In the end it seems that a yet unknown third person at CoCH did eventually share the report with Sarah at The Telegraph. I am glad this has happened and it takes a weight off of my mind…

But I do hope that Sarah and her employer maintain the absolute discretion of their source and that their source is not identified at CoCH by other means and, as a result, persecuted like so many whistleblowers are.

As I read the transcripts of evidence and other records and wrote my articles, I made sure to identify and highlight every time infection (sepsis or NEC) or symptoms of infection were diagnosed or considered for each baby - and it was considered for Every. Single. One. I even pointed my readers to articles and incidents at other hospitals that mirrored the circumstances and situation I had seen described in the CoCH report - looking at the types of infective bacterial agent common to NICU environments (including P.Aeruginosa, which I intentionally embeded in the middle of my article), how P.Aeruginosa can cause infection and death even in the fresh water supply of a brand new NICU, and how a completely innocent association between P.Aeruginosa infections and individual nursing staff can be found, and should more reasonably be handled.

I was pointing everyone towards the real culprit and cause in June and July 2023 - but at that point, couldn’t tell you why or how I came by that knowledge.

How does this disclosure change things?

As Mark Mayes points out in his most recent Youtube video, this report changes things in several ways. First, it tells us that there was awareness in senior management and senior medical officers at CoCH of an outbreak in the neonatal unit as early as May 2015 - before the first of the deaths that Lucy Letby was prosecuted for. Second, it tells us that they were not only aware, they were engaging countermeasures with limited success to address the outbreak. These measures included: (i) a risk mitigation stop/hold on transfers of babies from the level 3 unit at Arrowe Park Hospital in order to prevent them coming into a unit where they could become infected; and (ii) replacement, where available, of fixtures and fittings that were identified as harbouring P.Aeruginosa. Third, the report, in conjunction with the clinical guideline (a treatment policy), demonstrates that all babies were or were meant to be treated as if they were infected. This means they should all have been: (i) cared for under conditions of barrier nursing⁵ - something CoCH could not do because up to four neonates were crammed into a single nursery room and equipment and supplies were being stored in corridors and other areas of the active unit, and (ii) getting tested for infection and prophylactic treatment with a full course of strong antibiotics on admission to the unit - something that we know from my reviews of the clinical notes and testimonial evidence was often either not done, or was stopped by the then junior and poorly supervised doctors before the course of treatment could be properly completed. Fourth, and certainly if we are allowed to infer as Lucy Letby’s jury were instructed to, it tends to suggest a deliberate intention to misdirect away from or cover up ‘the hospital’ (as an entity of the entity known as The NHS) and ‘junior and largely unsupervised doctors’ roles in the death and adverse harms wrought upon these neonate’s premature and poorly bodies. This misdirection ensured that the narrative being promoted at the time was one where the babies, CoCH and NHS could all claim victimhood status, and the doctors could claim White Knight status, riding in to save their poor and unsuspecting patients from the evil babykiller nurse.

If nothing else, the idea that they could carve out between one-third and half of the babies who died at CoCH along with a small subset of the adverse events that affected those that didn’t die - and claim that whilst being similar in nature to the undisclosed others, these were murders and attempted murders by an evil nurse becomes preposterous when you, as I did, take a big picture view. That other neonates deaths at the same time and under similar circumstances were being hidden from the jury and public simply because they couldn’t link them to the same nurse, speaks volumes to the biases and sheer hubris of those tasked with the investigation. It cheapens these neonate’s lives - suggesting they are to be treated as little more than tokens to be divided between two ghastly buckets… babykiller nurse? or babykiller infection?

Erratum: I had incorrectly identified Arrowe Park as Level 1 - when they are Level 3.

1. https://www.telegraph.co.uk/news/2024/08/03/countess-of-chester-hospital-lucy-letby-bacteria-outbreak/ ::: If the article comes up behind a paywall, all you need to do is either put the URL into www.archive.org (The Way Back Machine), or open the link using a VPN to an overseas endpoint.

2. Inculpatory evidence tends to show the defendant’s involvement in the act or offence they have been charged with. Inculpatory evidence is that which is used to establish guilt.

3. Kong v Gulf Bank International (UK) Limited (Protect Intervening) [2022] EWCA Civ 941

4. Kumar v The Care Quality Commission: 2410174/2019

5. Barrier nursing is when patients are treated as if they may have an infection already and are kept secluded or excluded from contact with other patients. Nursing staff either only care for one patient, or completely change their gloves, gown and other PPE and wash with antiseptic solution when moving between patients. Nothing that is used on or near one patient is allowed to come into the exclusion area of another patient without first having been steralised.