How admirable that you and Norman Fenton are not allowing others to shut you down. I have not been following the Thirlwall inquiry and did not know how all the nursing staff were fully supporting her innocence - good that this is coming out. Clearly the emotionally 'blank' Lucy Letby was suffering PTSD. Not beyond reasonable doubt in so many ways. I will write to David Davis MP supporting his intervention.
Let us go back in time to when certain doctors, for what ever sincere reason/malevolent reason, suspected/targeted Lucy Letby. Their suspicions/targeting of LL grew but there was no proof and management didn't engage positively with said doctors, they didn't believe there was anything malevolent going on. With there being no hard evidence backing up suspicions was it necessary to allow this situation to develop into a police investigation, dubious charges being levelled and equally dubious convictions? Hindsight it might well be but a more satisfactory resolution would have seen things dealt with internally within the hospital and NHS, LL quietly having her career destroyed - removed from the nursing register. Hardly satisfactory but more satisfactory than the outcome we have.
That was probably tried by putting Lucy in the middle of 2016 on administrative duties. But she did not accept that and filed a grievance, which she won.
Amazing is that the hospital did not respond like hospitals in the US did: check every part of the nursery rooms, swipe every piece of equipment as well as the cots, scrape under the nails of everyone allowed in the NICU, etc. Look. Test.
In one hospital it turned out a piece of equipment - used for resuscitation - was colonized with a pathogen. In another hospital a pathogen was found under the nails of two nurses.
When it comes other Pseudomonas Aeruginosa, why is little to no attention given to the consultant who regularly visited the clinic with for children with Cystic Fibrosis - known to often carry this bacteria - and from there went to the CoCH NICU.
Baby, Jacob, in June 2015 COCH NICU had septicaemia & sent to Liverpool. On return MRI showed lumps were abscesses in elbow & ankle. So probably staph also in unit.
They targeted her, everyone had noticed and Letby had too that there were higher rates of death but these were reviewed at the time, there were more than what she was charged with and she wasn't always there or wasn't caring for the infant concerned. There was also a rise in stillbirths in the maternity unit but they didn't have a Letby to target for that. We have to be clear with none of it there's no evidence and she was one of the few that was full time, taking extra shifts and more experienced so took sicker babies. There were clearly long term issues with the unit, including infection control.
Those doctors were only doing two rounds a week and clearly junior doctors were doing most of the care, they were on the medical side of things and one of the first things they should have looked was the medical cover. Instead they were unprofessional and their behaviour well below standard. You just don't do that sort of thing and that's why she won the grievance. This grievance case was part of dealing with it internally as was temporarily moving to admin duties, they would have well and truly had a chance to put their position. Letby said in the police interview that it was presented to her there might be an issue with competency and engaged with that, it concerned her that there might have been some failing there. There's still no need to destroy a career at that stage, review, supervision of practice and other means of assessing whether that was the case would have worked.
The doctors then retaliated and that shouldn't have been allowed. It should be quite clear if they had managed to get rid of her they'd never have gone to the police, so it's doubtful even they truly thought that. By that stage it was a toxic situation. And then when it went to the police they should have have the pathologists and medical staff in as a start as this was rumour and innuendo and they clearly could not point to anything. When they did give notes to any one external these should have been random ones. Then seen what came out. I think Evans given access to random notes would have had every nurse doing nefarious things. And it's quite strange, there's things there like doctors putting in chest drains, not one, but three, one in the wrong position and not really the correct type of drain, but no, it's not them, its got to be the nurse. They didn't show the observations of the drains and whether they were working or not (air you have bubbling through a water seal, effusion you will have drainage).
A more satisfactory solution is not running nurses out of their profession, it's dealing with these issues properly and the consultants clearly did not. There was one at least who was said to come on to the unit and start yelling at people. Maybe a transfer of one or more people would have worked, there's other means of doing things things than leaving a already poorly staffed unit with less nursing staff which would increase risk to the infants in it.
In case you haven't noticed we live in an imperfect world with imperfect human beings the reason for this imperfection. Some might say the world is more than imperfect, that it is profoundly corrupt, that human beings are more than imperfect, that they also are profoundly corrupt. In such a world, and with such people, very often the least worst outcome is the best we can hope for. Lucy Letby losing her career would have been a better outcome than the outcome we have.
The CQC also visited the NICU in February and March 2016. Thirlwall Inquiry skates over what they discussed to focus witnesses minds on what its remit wants to know - what WASNT discussed: suspicions about Lucy Letby. Their remit starts from the position that she is guilty and they need to find people to blame for not joining forces with Brearey, Gibbs and Jayaram soon enough.
But in Thirlwall downloads we can read in the March 4th handwritten notes that they discussed: BLISS, staffing, pseudomonas and NEWS. The latter is the scoring system for detecting and treating sepsis. BLISS is the charity concerned with the safety and treatment of premature babies. In 2015 they produced a report ‘Hanging in the Balance’ relating to the issues you raise about staffing levels and acuity of neonates. So clearly the CQC were aware of bacteria in the NICU which CoCh had been aware of since May 2015, aware that it can cause sepsis which kills very quickly especially babies and neonates with no immune system in particular are highly susceptible. CQC did not mention sepsis or pseudomonas. One neonate deteriorated in mid February 2016 when they were in the Unit. CQC are due to speak at the Thirlwall Inquiry - will that March 4th note be discussed??
CQC didn’t mention sepsis or pseudononas in their June 2016 report, only staffing. They need to be asked about the handwritten note and why they didnt take urgent action and failed to even mention the bacteria and sepsis in their June report. That was two years before Lucy was arrested.
How competent&experienced the doctors were, was shown in 2014 when baby Noah was treated. His death barely made the press, probably because two junior doctors were involved. The coroner had some choice words from them. He got a significant amount of air pumped into his stomach. But amazingly, this ventilator pumped in air did not cause his death, not did he show all the tell-tale signs Dr. Dewi Davis said Lucy would have caused by pumping in air. Baby Noah died because the two doctors did not realize that had made a basic mistake: they had put the tube in his esophagus instead of in his trachea. He did for awhile not get any air into his lungs. Why this case was not mentioned to exonerate Lucy of "air pumped into the stomach" I will never understand. Apparently, by now Dr. Evans has walked it back - and changed the accusation to air into a vein. Which does not matter because the judge told the jury they dodged not have to agree how she did it, just "that she did it".
I read the mothers' testimony in the Thirwall inquest. How they were treated before/during/just after delivery. It sounds like a house of horrors.
See this Feb 2017 BBC article that discussed that staffing levels were low at CoCH neonatal. Back in Feb 2017, there was no mention re "killer nurse" was responsible for the 13 deaths over 2 years, 8 in 2015 and 5 in 2016 and said there was no single cause.
Staffing 'inadequate' at Chester baby death hospital
The review recommended increasing staffing and improving leadership.
It found "significant gaps" in medical and nursing rotas, "poor decision-making" and "insufficient senior cover".
'No single cause'
Medical staffing was "sufficient" for a special care unit but "inadequate" for high dependency, the report said.
Transport services in Cheshire and Merseyside were "under-resourced", it added.
The Countess of Chester, which looks after about 400 babies a year, stopped providing care for babies born earlier than 32 weeks in July last year. (July 2016)
The Countess of Chester Hospital NHS Trust has been told it must improve following unannounced inspections carried out by the Care Quality Commission (CQC).
A report into the hospital trust has been published today (February 14) by the CQC, detailing its findings. It says that the hospital trust does not meet required standards across the board - except for the level of care, which was deemed to be good.
The inspections were carried out between October and November last year. They came immediately after it was announced by Cheshire Police that the hospital was under a corporate manslaughter investigation following the Lucy Letby convictions.
Meanwhile, Lucy Letby has been scapegoated for the many problems caused by reduced staffing, reduced levels of experienced neonatal staff and rota cover. See the nearly nonstop killer nurse articles published over the past years, i counted nearly 24: https://www.cheshire-live.co.uk/all-about/countess-of-chester-hospital
Many NHS trusts have suffered reduced funding for decades resulting in reduced staffing levels and quality of Healthcare provided. Work visas for American nurses were cancelled in 2011, FYI.
Indeed, the CoCH neonatal ward went back to being a Level-1 unit. But they also removed (at least) three cots, and upped the staffing. What many people not realize is that the Consultants did rounds in the NICU twice a WEEK. No wonder for them crashes etc. were "unexpected".
Many parent wanted answers what happened to their child. They were badly treated by CoCH in their quest for information. So a number of them hired lawyers. That all stopped when, deus ex machina, the killer nurse was discovered.
In 2015 - per statements of the cleaners - cleaning service were reduced.
Yeh there are multiple reasons which can explain the spike in deaths, none of which involve murder. Thirwall will be tasked with continuing the pretence as blaming Lucy will be the easiest way for COCH to avoid huge negligence payouts as I am guessing their lawyers will argue that Lucy broke the employer/employee relationship such a degree that they hospital cannot be held responsible
It's worse than that. Even as evidence arises from the Thirlwall inquiry irrefutably showing Letby's innocence, Lady Thirlwall and the barristers are turning themselves inside out to claim it continues to prove Letby's guilt. More incredible, even as new evidence is brought to the fore that the police either missed or overlooked (intentionally or accidentally) which shows Dewi Evan's evidence was yet more tendatious biased and fabricated nonsense - the inquiry is overlooking that too in their race to ensure their findings are all about how the NHS managers failed to get rid of the (not) killer nurse, and avoiding any suggestion that the trial judge and jury and general public were misled.
Goes deeper than that. There is an underlying agenda as there is with many news stories that are massively in the public eye. Even the name Operation hummingbird was chosen for a reason by those who handle the police . My first article on it on Sept last year analysed that https://callystarforth.substack.com/p/operation-hummingbird
How admirable that you and Norman Fenton are not allowing others to shut you down. I have not been following the Thirlwall inquiry and did not know how all the nursing staff were fully supporting her innocence - good that this is coming out. Clearly the emotionally 'blank' Lucy Letby was suffering PTSD. Not beyond reasonable doubt in so many ways. I will write to David Davis MP supporting his intervention.
From evidence in TI.
Baby I . Born at 27 weeks gestation and weighing <1kg. Multiple transfers to and from level 3 unit.
Cardiac arrests on 13th/14th/15th/23 rd October.
LL on duty 12th/13 th/22nd
So this was not a well stable baby by any means. And who has been arrested for the collapses on the 14 and 15th ?
Just when you thought the extent of the miscarriage couldn't get any more damning...
Well done you for keeping at it.
Let us go back in time to when certain doctors, for what ever sincere reason/malevolent reason, suspected/targeted Lucy Letby. Their suspicions/targeting of LL grew but there was no proof and management didn't engage positively with said doctors, they didn't believe there was anything malevolent going on. With there being no hard evidence backing up suspicions was it necessary to allow this situation to develop into a police investigation, dubious charges being levelled and equally dubious convictions? Hindsight it might well be but a more satisfactory resolution would have seen things dealt with internally within the hospital and NHS, LL quietly having her career destroyed - removed from the nursing register. Hardly satisfactory but more satisfactory than the outcome we have.
That was probably tried by putting Lucy in the middle of 2016 on administrative duties. But she did not accept that and filed a grievance, which she won.
Amazing is that the hospital did not respond like hospitals in the US did: check every part of the nursery rooms, swipe every piece of equipment as well as the cots, scrape under the nails of everyone allowed in the NICU, etc. Look. Test.
In one hospital it turned out a piece of equipment - used for resuscitation - was colonized with a pathogen. In another hospital a pathogen was found under the nails of two nurses.
When it comes other Pseudomonas Aeruginosa, why is little to no attention given to the consultant who regularly visited the clinic with for children with Cystic Fibrosis - known to often carry this bacteria - and from there went to the CoCH NICU.
Reported in Chester paper Oct 1.
Baby, Jacob, in June 2015 COCH NICU had septicaemia & sent to Liverpool. On return MRI showed lumps were abscesses in elbow & ankle. So probably staph also in unit.
All the fumbling and bumbling by doctors was not discussed. On the ward as well as in the maternity ward.
They targeted her, everyone had noticed and Letby had too that there were higher rates of death but these were reviewed at the time, there were more than what she was charged with and she wasn't always there or wasn't caring for the infant concerned. There was also a rise in stillbirths in the maternity unit but they didn't have a Letby to target for that. We have to be clear with none of it there's no evidence and she was one of the few that was full time, taking extra shifts and more experienced so took sicker babies. There were clearly long term issues with the unit, including infection control.
Those doctors were only doing two rounds a week and clearly junior doctors were doing most of the care, they were on the medical side of things and one of the first things they should have looked was the medical cover. Instead they were unprofessional and their behaviour well below standard. You just don't do that sort of thing and that's why she won the grievance. This grievance case was part of dealing with it internally as was temporarily moving to admin duties, they would have well and truly had a chance to put their position. Letby said in the police interview that it was presented to her there might be an issue with competency and engaged with that, it concerned her that there might have been some failing there. There's still no need to destroy a career at that stage, review, supervision of practice and other means of assessing whether that was the case would have worked.
The doctors then retaliated and that shouldn't have been allowed. It should be quite clear if they had managed to get rid of her they'd never have gone to the police, so it's doubtful even they truly thought that. By that stage it was a toxic situation. And then when it went to the police they should have have the pathologists and medical staff in as a start as this was rumour and innuendo and they clearly could not point to anything. When they did give notes to any one external these should have been random ones. Then seen what came out. I think Evans given access to random notes would have had every nurse doing nefarious things. And it's quite strange, there's things there like doctors putting in chest drains, not one, but three, one in the wrong position and not really the correct type of drain, but no, it's not them, its got to be the nurse. They didn't show the observations of the drains and whether they were working or not (air you have bubbling through a water seal, effusion you will have drainage).
A more satisfactory solution is not running nurses out of their profession, it's dealing with these issues properly and the consultants clearly did not. There was one at least who was said to come on to the unit and start yelling at people. Maybe a transfer of one or more people would have worked, there's other means of doing things things than leaving a already poorly staffed unit with less nursing staff which would increase risk to the infants in it.
In case you haven't noticed we live in an imperfect world with imperfect human beings the reason for this imperfection. Some might say the world is more than imperfect, that it is profoundly corrupt, that human beings are more than imperfect, that they also are profoundly corrupt. In such a world, and with such people, very often the least worst outcome is the best we can hope for. Lucy Letby losing her career would have been a better outcome than the outcome we have.
The CQC also visited the NICU in February and March 2016. Thirlwall Inquiry skates over what they discussed to focus witnesses minds on what its remit wants to know - what WASNT discussed: suspicions about Lucy Letby. Their remit starts from the position that she is guilty and they need to find people to blame for not joining forces with Brearey, Gibbs and Jayaram soon enough.
But in Thirlwall downloads we can read in the March 4th handwritten notes that they discussed: BLISS, staffing, pseudomonas and NEWS. The latter is the scoring system for detecting and treating sepsis. BLISS is the charity concerned with the safety and treatment of premature babies. In 2015 they produced a report ‘Hanging in the Balance’ relating to the issues you raise about staffing levels and acuity of neonates. So clearly the CQC were aware of bacteria in the NICU which CoCh had been aware of since May 2015, aware that it can cause sepsis which kills very quickly especially babies and neonates with no immune system in particular are highly susceptible. CQC did not mention sepsis or pseudomonas. One neonate deteriorated in mid February 2016 when they were in the Unit. CQC are due to speak at the Thirlwall Inquiry - will that March 4th note be discussed??
CQC didn’t mention sepsis or pseudononas in their June 2016 report, only staffing. They need to be asked about the handwritten note and why they didnt take urgent action and failed to even mention the bacteria and sepsis in their June report. That was two years before Lucy was arrested.
One of the nurses made redundant - like you mention - stated in an interview "There, but for the Grace of God, it could have been me".
How competent&experienced the doctors were, was shown in 2014 when baby Noah was treated. His death barely made the press, probably because two junior doctors were involved. The coroner had some choice words from them. He got a significant amount of air pumped into his stomach. But amazingly, this ventilator pumped in air did not cause his death, not did he show all the tell-tale signs Dr. Dewi Davis said Lucy would have caused by pumping in air. Baby Noah died because the two doctors did not realize that had made a basic mistake: they had put the tube in his esophagus instead of in his trachea. He did for awhile not get any air into his lungs. Why this case was not mentioned to exonerate Lucy of "air pumped into the stomach" I will never understand. Apparently, by now Dr. Evans has walked it back - and changed the accusation to air into a vein. Which does not matter because the judge told the jury they dodged not have to agree how she did it, just "that she did it".
I read the mothers' testimony in the Thirwall inquest. How they were treated before/during/just after delivery. It sounds like a house of horrors.
See this Feb 2017 BBC article that discussed that staffing levels were low at CoCH neonatal. Back in Feb 2017, there was no mention re "killer nurse" was responsible for the 13 deaths over 2 years, 8 in 2015 and 5 in 2016 and said there was no single cause.
Staffing 'inadequate' at Chester baby death hospital
Published 8 February 2017 https://www.bbc.com/news/uk-england-merseyside-38901317
The review recommended increasing staffing and improving leadership.
It found "significant gaps" in medical and nursing rotas, "poor decision-making" and "insufficient senior cover".
'No single cause'
Medical staffing was "sufficient" for a special care unit but "inadequate" for high dependency, the report said.
Transport services in Cheshire and Merseyside were "under-resourced", it added.
The Countess of Chester, which looks after about 400 babies a year, stopped providing care for babies born earlier than 32 weeks in July last year. (July 2016)
------------------------------
Meanwhile, lost in the flood of recent killer nurse articles during 2022 to 2024, (see the nearly nonstop killer nurse articles published over the past years, i counted nearly 24: https://www.cheshire-live.co.uk/all-about/countess-of-chester-hospital )
this devastating news :
Cheshire Police announced feb 2024 that the hospital was under a corporate manslaughter investigation following the Lucy Letby convictions see:
https://www.cheshire-live.co.uk/news/chester-cheshire-news/countess-chester-hospital-trust-needs-28626894
The Countess of Chester Hospital NHS Trust has been told it must improve following unannounced inspections carried out by the Care Quality Commission (CQC).
A report into the hospital trust has been published today (February 14) by the CQC, detailing its findings. It says that the hospital trust does not meet required standards across the board - except for the level of care, which was deemed to be good.
The inspections were carried out between October and November last year. They came immediately after it was announced by Cheshire Police that the hospital was under a corporate manslaughter investigation following the Lucy Letby convictions.
Meanwhile, Lucy Letby has been scapegoated for the many problems caused by reduced staffing, reduced levels of experienced neonatal staff and rota cover. See the nearly nonstop killer nurse articles published over the past years, i counted nearly 24: https://www.cheshire-live.co.uk/all-about/countess-of-chester-hospital
Many NHS trusts have suffered reduced funding for decades resulting in reduced staffing levels and quality of Healthcare provided. Work visas for American nurses were cancelled in 2011, FYI.
Indeed, the CoCH neonatal ward went back to being a Level-1 unit. But they also removed (at least) three cots, and upped the staffing. What many people not realize is that the Consultants did rounds in the NICU twice a WEEK. No wonder for them crashes etc. were "unexpected".
Many parent wanted answers what happened to their child. They were badly treated by CoCH in their quest for information. So a number of them hired lawyers. That all stopped when, deus ex machina, the killer nurse was discovered.
In 2015 - per statements of the cleaners - cleaning service were reduced.
Yeh there are multiple reasons which can explain the spike in deaths, none of which involve murder. Thirwall will be tasked with continuing the pretence as blaming Lucy will be the easiest way for COCH to avoid huge negligence payouts as I am guessing their lawyers will argue that Lucy broke the employer/employee relationship such a degree that they hospital cannot be held responsible
It's worse than that. Even as evidence arises from the Thirlwall inquiry irrefutably showing Letby's innocence, Lady Thirlwall and the barristers are turning themselves inside out to claim it continues to prove Letby's guilt. More incredible, even as new evidence is brought to the fore that the police either missed or overlooked (intentionally or accidentally) which shows Dewi Evan's evidence was yet more tendatious biased and fabricated nonsense - the inquiry is overlooking that too in their race to ensure their findings are all about how the NHS managers failed to get rid of the (not) killer nurse, and avoiding any suggestion that the trial judge and jury and general public were misled.
Goes deeper than that. There is an underlying agenda as there is with many news stories that are massively in the public eye. Even the name Operation hummingbird was chosen for a reason by those who handle the police . My first article on it on Sept last year analysed that https://callystarforth.substack.com/p/operation-hummingbird