Lucy Letby repeatedly raised the alarm about the poor care of babies in the hospital where she worked, according to bombshell documents obtained by The Mail on Sunday.
The case against the former nurse, who was convicted of the murder of seven newborns and the attempted murder of seven more at the Countess of Chester Hospital, has come under intense scrutiny after experts called into question key planks of the prosecution.
Letby, 35, was convicted on the basis of contested statistical probabilities and disputed theories about how she might have inflicted harm on the children. The juries reached their verdict despite the absence of any forensic or CCTV evidence and the lack of a convincing motive.
Now internal management forms at the hospital have revealed how she formally highlighted apparent failures of care in her neonatal unit – shortly before she was removed from her duties at the request of a senior doctor. The police were subsequently contacted to investigate whether the deaths were caused by murder.
Last night the lawyer heading Letby’s new legal team claimed that senior medics had targeted her in revenge for her whistleblowing. A panel of international experts recently concluded that no murders were committed and instead the babies collapsed or died due to either poor care or natural causes.
The documents – called Datix Admin and Management Forms – cover a number of medical emergencies in the unit in 2015 and 2016.
The group which investigated Letby’s complaints included Dr Stephen Brearey, who was one of two doctors who would later raise questions about whether she was ‘purposely harming babies’.
On June 30, 2016 Letby used the system to report an incident a week earlier when a baby had suffered a ‘sudden acute collapse requiring resuscitation’, only for staff dealing with the emergency to find that the sodium bicarbonate infusion required to deal with the crisis was not available.
The lawyer heading Letby’s new legal team claimed that senior medics had targeted her in revenge for her whistleblowing
A report made by Lucy Letby in June 2016 when a baby had suffered a ‘sudden acute collapse requiring resuscitation’
Another report by Letby in June 2016 identified failures by doctors over the administration of intravenous medication
In August 2023 Lucy Letby was convicted of the murders of seven infants and the attempted murders of seven others between June 2015 and June 2016
Dr Brearey’s investigating group recommended new measures to ‘ensure adequate stock levels in future’. Letby filed a second report about another baby on the ward who had collapsed three hours after the first incident, saying that ‘resources were not available on Unit’ to deal with the emergency.
Dr Brearey later amended her incident form to state that the medical resources mentioned were not necessary to deal with the incident and in any case were not ‘routinely kept on the unit’ – but then conceded that due to ‘a recent increase in usage’ delivery would be arranged.
Another report by Letby in June 2016 identified failures by doctors over the administration of intravenous medication. Dr Brearey’s group concluded that nurses should check the equipment ‘on an hourly basis’ and that Dr Brearey would ‘update new doctors at induction’.
At Dr Brearey’s request, Letby was transferred from clinical duties the following month. She was arrested in 2018. Other reports by Letby included the ‘unexpected death’ of a baby in August 2015 which concluded that ‘neonatal care was appropriate… it is unlikely any changes in management would have prevented this sad outcome’; the deterioration of an infant after ventilation records were not recorded for a 12-hour period; and a ‘chest drain complication’ due to a lack of needles on the ward.
The revelations come after two television documentaries broadcast this month highlighted mounting questions about the safety of Letby’s convictions.
Dr Neena Modi, ex-president of the Royal College of Paediatrics and Child Health, told ITV’s Lucy Letby: Beyond Reasonable Doubt?: ‘It’s been deeply disturbing that one can have such a… tremendously important trial that seems to have been conducted with so many flaws.’
BBC’s Panorama featured expert Dr Mike Hall, who warned that flaws in the evidence produced by Letby’s new defence team could undermine her chance of a fair retrial.
Dr Hall, who prepared reports for Letby’s first trial in 2022 and sat through ten months of hearings, was baffled not to be called by her original team to contest the prosecution’s evidence.
He told the BBC: ‘In terms of natural justice, I don’t think she should have been found guilty… there is no evidence of inflicted injury in the babies.’
Letby’s lawyer, Mark McDonald, who has submitted an application to the Criminal Cases Review Commission, said: ‘Lucy was a hard working, experienced nurse who loved her job and would never harm any child which is why she would not let any fault pass. This was a neonatal unit in crisis and she consistently formally reported issues.
‘She was a whistleblower – but instead of listening to her they went for her instead.’
An official inquiry led by Lady Justice Thirlwall has been launched into events at the hospital and will examine: the conduct of all junior and senior staff; the experiences of bereaved parents and the effectiveness of NHS management and structures.
Lady Thirlwall has stressed she will not be ‘scrutinising’ Letby but ‘the actions of all those who were in the hospital’. She will publish her report early next year.
A spokesman at the Countess of Chester Hospital NHS Foundation Trust said: ‘Due to the Thirlwall Inquiry and the ongoing police investigations, it would not be appropriate to comment further at this time.’
