Wokery and Government overreach are the great issues of the early 2020s. Lucy Letby isn’t of the same order. Nevertheless, this young woman, of previously blameless character, has been imprisoned for the rest of her life on circumstantial evidence. With rare exceptions, the media have relished turning her into a ghoul. They are ably assisted by the Cheshire Constabulary who, post-trial, drip-feed corroborative detail to add verisimilitude, as in Gilbert and Sullivan’s ‘The Criminal Cried’. They tell the media that Letby kept an “encrypted diary”, with “L.O.” having some sinister meaning. In fact, Letby has a cursive script and it’s L.D. not ‘L.O.’, being nurses’ common shorthand for ‘Long Day’, or a 12-hour shift. They’ve auctioned the film rights for their investigation, with ITV placing the winning bid. I’d advise ITV to check carefully for spin.
No one who cares about justice should be comfortable with this case. To briefly re-cap: Ms. Letby worked at the Countess of Chester neonatal unit from 2012. From at least 2014 this was a Level II unit, meaning that it took very premature babies. From mid-2015 to mid-2016, 15 infants died and a similar number had major collapses. This was far more than in the preceding and subsequent periods (figure 1). The consultants raised alarms, leading to internal investigations then a review by the Royal College of Paediatrics and Child Health (RCPCH), commissioned in mid-2016.
Concern about Ms. Letby arose early, and she was moved to a desk job in July 2016. In response she began a grievance procedure, claiming that doctors were persecuting her. At this stage their concern surely related to competence; no Royal College would touch an investigation that should properly be a police matter. Assertions that “Doctors suspected Letby from 2015” should be read in this light. Post-mortems, performed for six of the seven deaths for which Letby ultimately was convicted, recorded “natural causes”.
Initial findings were in Ms. Letby’s favour. Her grievance was upheld and the RCPCH report, released at the end of 2016, expressed concern about the unit’s staffing and safety, saying that it was unsuitable for Level II. By then it had been downgraded to Level I anyway, with the most premature and sickliest babies delivered or sent elsewhere. There’s no mention of Ms. Letby or any other staff member, but it is beyond credulity, given the consultants’ suspicions, that she wasn’t quietly discussed. Doubtless there were separate confidential communications. They can’t have been damning, for Countess of Chester management notoriously forced the consultants to apologise and indicated that Letby would resume clinical nursing. Unhappy with these outcomes, the consultants involved the police in the spring of 2017, igniting the powder trail.
A 10-year retired paediatrician and professional expert witness, Dr. Dewi (David) Evans was recruited by the police. By his account he reviewed 30-something deaths and collapses, distinguishing 15 (eight murders and seven attempted murders) for which Letby was charged. Unfortunately, we don’t have his workings, nor the exact reason why he excluded seven deaths, except that he told talkRADIO that “they died for the usual problems why small babies die: haemorrhage, infection, congenital problems”. Nor do we know why the judge threw out one murder charge.
Now, go to figure 1 and examine the critical mid-2015 to mid-2016 period. Even if one removes the seven deaths for which Letby was convicted (orange and blue), the remaining eight (grey) form an excess cluster compared with the previous period (the subsequent period is not comparable owing to the unit’s downgrade). That means that we are asked to believe that Letby’s murders coincided, quite by chance, with a spike of other excess deaths, all of them unsurprising. I’d accept this if Letby was a strychnine poisoner, if seven babies died from strychnine and seven died owing to a concurrent viral outbreak. It’d be shocking, but clear. But these were highly-vulnerable babies, mostly premature and with other health issues. Do the suspicious and non-suspicious excesses really divide so precisely? A lifetime in biology and medicine tells me it’d be remarkable if they did. Biology and medicine are full of grey zones.
Dr. Evans says that – very correctly – he was working blind to whether Letby was present at a death or collapse or not. But, given the complexity, why was he the sole reviewer? And how does that much-published list of nurses’ presence and events look if all events, suspicious or otherwise, are included? Was she also present at many non-suspicious events? Maybe she just worked a lot.
The causes of death Dr. Evans found variously included air embolism in the blood (infants A, D) or stomach (C, I and P) or interference with nasogastric tubes (infants E,O). They differed from the natural causes identified at post-mortem by coroners’ pathologists, from whom we heard nothing at the trial. Methods of attempted murders included insulin poisoning (infants F and L), excessive feeding (infant G) and traumatic assault (infant N).
Even if we reject the contemporaneous post-mortems and accept Dr. Evans’s later diagnoses, air embolism is not proof of deliberate injection. A PubMed search combining “air”, “embolism” and “neonates” yields 271 hits. If I then add “infection” I retain 37 hits and if I instead add “enterocolitis”, I have 17. Sato and colleagues describe an infant with bacterial peritonitis producing so much gas that ultrasound revealed “intravascular microbubbles moving into a pulmonary artery”. Smith and Els describe four fatal cases of infant cardiac embolism (i.e., air in the heart) and underscore the hazard of air being accidentally or negligently introduced in infants with difficult venous access. Beluffi and Peroti describe air embolism as a “rare complication of intensive care, noting links to enterocolitis (i.e., gut infection), surgical procedures and infant respiratory distress syndrome (which they call hyaline membrane disease)”.
The possible role of infection should be underscored. The Chester unit’s sewage system, or that of the ward above, was defective, providing an obvious source of infection. That is why the hospital plumber, called as a defence witness, visited repeatedly. Contaminated water systems notoriously cause clusters of neonatal unit deaths. What outbreak investigation was done at the time? Any? None? Were sewage leaks the reason why the Unit was later rebuilt?
Turning to the two insulin cases, which played a major role in the conviction: why was no alarm raised about extraordinarily high readings? A clinical biochemistry department signed them off and a paediatrician received them. Did either read them? The second case (Baby L) was in April 2016, when the unit staff were acutely aware of a string of adverse events. For baby F, in August 2015, there’s the question of how the insulin was delivered. The prosecution alleged it was via an intravenous feed bag rigged to run over 48 hours. But this bag had to be changed after Letby went off-shift owing to problems with the line. As her defence pointed out, it’s inconceivable that it’d be replaced with the one other bag that she’d also spiked or that, if she’d spiked multiple bags, there was no cluster of insulin-poisonings. What really happened is deeply uncertain, and the blood samples were discarded long ago.
Dr. Evans’s analysis was one major factor in Letby’s conviction. The other was her own notes, most notoriously one on green paper (figure 2). This includes the much-quoted phrases: “I killed them on purpose because I’m not good enough to care for them”, “I’m a horrible evil person” and “I am evil, I did this”.
Reading the note is tricky. Words overlap and those on the same line do not always belong to the same sentence. The most convincing decrypt I’ve seen asserts that it was written in five parts shown, colour coded, in figure 3 (though I’d put everything in block capitals into the grey block).
Much is a stream of fear and self-loathing but what’s critical is in green, bottom right, below the heavily encircled “HATE”. This reads: “They accused; they went…”, followed by those claimed confessions. “Accused” isn’t certain to me, being obscured by the heavy circle around “HATE”, but the meaning is clear from “They went”, which is to say that “They [the police] asserted that…”. Read that way, it’s a shell-shocked woman describing a police interview, not a confession.
I do not know that Ms. Letby is innocent. I wouldn’t be surprised to learn she wasn’t the world’s best nurse, nor that the doctors had legitimate concerns about her competence. But I am far from convinced that she is a murderess on the evidence that has been presented.
She worked on a Level II unit that, based on the RCPCH report, wasn’t fit for purpose. Her ‘killing spree’ coincided with an excess of other deaths that the principal expert witness says were “due to the usual problems of small babies”. Air embolus – if it was the cause of death – was diagnosed long after the event and can arise for other reasons besides malicious injection. Her ‘confession note’ can be construed very differently. In a remarkably similar case, a Dutch nurse, Lucia de Berk, was convicted of neonatal murders based on circumstantial evidence and an ambiguous diary, then exonerated. Many think that Letby’s defence barrister failed to make the best of her case, with no expert bar the plumber called on her account. It is vital that she is allowed an appeal.
It is vital too that the pending Statutory Inquiry interprets its brief as widely as possible, and considers the possibility, however small, that it is built upon a false premise. The Countess of Chester Hospital was not a happy place to work. In December 2015, one unnamed paediatrician wrote to the management: “Over the past few weeks I have seen several medical and nursing colleagues in tears… they get upset as they know that the care they are providing falls below their high standards,” adding “chronically overworked” and “no one is listening”. Doctors and the hospital management clearly disliked and distrusted each other. Dr. Gilby, who became CEO after Letby’s arrest, is now suing for constructive dismissal, asserting she was bullied and undermined by the Trust Chairman.
Isn’t this the perfect setting for care to go horribly awry, without foul play? Or have we reached the point where it becomes expedient to blame miscreant nurses for the NHS’s failings, just as our 17th Century forebears attributed societal calamities to witches?
Dr. David Livermore is a retired Professor of Medical Microbiology at the University of East Anglia.