Why Letby has been subjected to one of the Biggest Miscarriages of Justice in UK History

Professor Fenton and I on Outspoken with Dan Wootten

The last couple of weeks have rushed past like a whirlwind. If you’ve been trying to keep up, I admire your tenacity.

Staffing

While we were aware at least from the RCPCH report that there were some staffing issues on the neonatal unit at CoCH, details from the Thirlwll Inquiry have shown just how severe the staffing issues were. Thanks to the inquiry the public now have visibility of the internal risk registers for the unit, which included a red high risk to patient safety that described the unit as understaffed and underskilled. The unit was at a point where there was often only two neonatal specialty-trained nurses available on the rota to work, one of whom was Letby. The unit was regularly taking on bank (hospital staff working extra shifts) and agency (nurses from an external 3rd-party supplier) nurses in order to ensure something even approaching an operational staffing level. However, three key decisions made nursing in the neonatal unit an unsafe occupation. First, that the unit was taking on so many very premature and poorly babies that were sometimes so borderline they would have been best served being transferred to a Level 3 Neonatal Intensive Care Unit (NICU). Second, that as a cost-saving measure from the late 1990’s through into the 2000s the hospital had as a policy decision been making senior and more qualified and experienced neonatal nurses redundant, in favour of bringing in larger numbers of cheaper Band 5 new graduate nurses. And third, that the unit was regularly being allowed to stay open with less, sometimes significantly less, than the minimum number of nurses required for the number and acquity of neonates that were inpatient at the time.

There was a similar risk recorded for the medical staff of the neonatal unit, describing a doctor shortage that was impacting medical cover on the unit. This explains what we see in the evidence from both Letby trials; the number of junior and trainee doctors being left largely unsupervised to perform invasive procedures and make care decisions for premature and poorly neonates with complex care needs. It expains why the doctors who during the first trial were lauded as consultants, were actually all only second and third year post-graduation, themselves. It often gets lost in the clinical titles, and the general public often don’t realise, but the most senior doctors on the unit sometimes were what then were called Registrars. A registrar is simply a graduate who has survived their two Foundation Years (the first two years out of medical school) and been accepted as a proper doctor in their 3rd year of practice. They are still very green, still honing their clinical skills, and still have a *lot* to learn.

The public should also be becoming more acutely aware of one of the most glaring issues - that CoCH was running a neonatal unit that lacked, sometimes seemingly any, suitably trained and experienced neonatologists. A neonate is not the same as other children. Neonatology is not paediatrics. Neonatologists are specialists trained specifically to deal with newborn and premature babies, while paediatricians do health checks and provide medical care to children. Neonatologists are specially trained to deal with birth defects, metabolic imbalances and infections in the premature baby, which is one of the two likely reasons why when some of the poorly premature neonates from CoCH were sent to Liverpool Women’s Hospital and Arrowe Park who employ neonatology consultants, they very quickly got better. That, and the fact that they were taken out of the heavily pathogen-infested environment at the CoCH.

Bacterial Infestation

As many of my readers already know, from the beginning my position has been that bacterial infection more appropriately explains a larger number of the neonate’s illnesses and deaths at CoCH than a murderer - both those that Letby was prosecuted for harming and those that she was not. The jury was sheltered not just from the evidence that there were significantly more babies (at least another ten) who died on the unit during 2015-2016 than the seven Lucy was charged with murdering, but also from much of the evidence that would lead any critical thinking and unbiased clinical person to see that these neonates were seriously unwell. During the trials we were told that they were ‘stable’, ‘doing well’ and had ‘no issues’, and that there was no reason other than something Lucy must have done to explain why they became unwell. However, these statements and this overall position fails to acknowledge a wealth of salient facts that speak to two things. First, that the neonatal unit and whole sections of CoCH were infested with potentially deadly bacteria that was causing sometimes fatal nosocomial infection. And second, that the CoCH hospital had an extremely poor track record on dealing with infection and sepsis. Evidence from the inquest into the death of Olly Stopforth shows that neither of these issues had been sufficiently resolved even four years after Letby had been dismissed, in 2020.

The latest revelation from Thirlwall has been that pseudomonas aeruginosa, one of the three bacteria that I identified in only my second report on the Letby clinical evidence and transcripts, was known to be infesting some of the taps on the neonatal unit. Remember that while the feeds that babies on the unit would have been receiving were probably made up with sterile or bottled water from pharmacy, not that this guaranteed a bacteria-free water supply, mothers expressing breastmilk for their neonates on the unit would have been washing the various parts and bottles from the breast pump devices under these taps. Let that sink (no pun intended) in. When pseudomonas can create a biofilm on almost any surface, and can survive on a dry surface only to reactivate when that surface becomes wet again, this creates the potential that babies on the unit could potentially have become infected even from the maternally expressed and strategically important colostrum that is meant to initially charge the baby’s immune system with antibodies.

Outspoken with Dan Wootton

Given the almost daily change in public and professional opinion about the case, and leaving aside that many in the media are still firmly in the babykiller and if you disagree you’re a consipracy theorist camp, I agreed to appear with Professor Norman Fenton on the Outspoken show that Dan Wootton puts out each week.

As many of my long-term readers know, I am a lecturer currently installed in the nursing, midwifery and palliative care school at King’s College London. I originally completed two years of nursing school and many hundreds of hours of clinical training in my undergraduate years. While I did not stay on to complete to register as a nurse, I moved into computer science and regularly did IT projects in hospitals and health departments. I was suitably positioned for many of those projects because I had some understanding for what clinical staff wanted to do with the computer systems I was involved in developing, and how they would use them. I also spoke their ‘language’. I also hold three law qualifications - a Diploma in Law, a GDL that focused on health and cyber law, and a masters degree known as an LLM. My PhD in computer science specifically focused on a more credible aproach to the use of medical records in so-called big data - the Learning Health System. As Dan suggests, between my original couple of years of training in nursing, the health law component of my GDL, my career and PhD in health information technology and my current position as a lecturer in digital technologies for healthcare within a nursing school, I have qualifications and experience that made me a suitable person to be evaluating the clinical and testimonial evidence and documentation from this case.

As time and income permits, and with the support of my subscribers, I hope to continue doing so.