Breathing tubes became “dislodged” during 40% of trainee shifts worked by serial killer Lucy Letby in Liverpool, prior to the murder and attempted murder of babies at another hospital in Chester, an inquiry has heard.
The former neonatal nurse was sentenced to life imprisonment last year for murdering seven babies and attempting to murder others at the Countess of Chester Hospital between the summers of 2015 and 2016.
On the third day of the Thirlwall inquiry looking into how Letby, 34, was able to commit her crimes, the inquiry was told that Liverpool Women’s Hospital had carried out an audit showing cases of breathing tubes becoming dislodged.
Letby is understood to have carried out two work placements at the hospital between October and December 2012, and January and February 2015.
In his opening statement on Thursday, Richard Baker KC, representing nine families, said collapses in neonatal units involving “unusual” complications such as dislodgement of endotracheal tubes are “uncommon”.
“It generally occurs in less than 1% of shifts,” he told the inquiry.
“You will hear that an audit carried out by Liverpool Women’s Hospital recorded that whilst Lucy Letby was working there, dislodgement of endotracheal tubes occurred in 40% of shifts that she worked.
“One may wonder: why?”
He added that the indictments and convictions against her “did not tell the full story”.
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‘To lose a baby is heartbreaking experience, which nobody should go through’
‘Basic failures’
Earlier this year, a jury found Letby guilty at retrial of attempting to murder a baby girl known as Child K by deliberately dislodging her breathing tube in February 2016.
Child K was transferred to a specialist hospital where she died three days later.
Letby was initially charged with Child K’s murder but the allegation was dropped in June 2022.
Meanwhile, the third day of the inquiry heard that “basic failures” at the Countess of Chester Hospital where Letby worked had “fatal consequences”.
Peter Skelton KC, representing another seven families, detailed five “basic failures” by the hospital.
Speaking at Liverpool Town Hall, he said: “The first failure was to conduct swift, careful and methodical investigations into why each of the deaths occurred and whether there were connections between the deaths.”
He added: “That was a major and catastrophic failure.”
Mr Skelton said it meant vital information was overlooked, with “fatal consequences” for other children.
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‘Deaths should have been escalated’
Mr Skelton said the cluster of deaths and collapses should have been escalated to senior management within the hospital trust immediately, so they could have overseen investigations.
“It should have been in the minds of those conducting and overseeing the investigations that the cluster of unexpected and unexplained deaths might have been caused by the criminal acts of a member of hospital staff,” he said.
‘Staff should have kept minds open’
The barrister said a report into Beverley Allitt, a nurse who killed children at Grantham Hospital, Lincolnshire, in 1991, sought to ensure that healthcare staff were prepared to keep their minds open to the possibility of criminal conduct.
Mr Skelton also noted how in May 2015, nurse Victorino Chua was sentenced for murdering patients at Stepping Hill Hospital.
“It is difficult to understand why events at Stepping Hill did not at the very least alert those at the Countess of Chester from the start that the cluster of unexpected deaths were the result of potential criminality and that active steps were required to rule out that possibility,” he said.
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Serial killer case formed part of Letby’s training – inquiry
‘Police and coroner should have been informed’
Mr Skelton said the police and coroner should have been informed at the outset, which could have had a “profound effect” on the course of events.
He told the inquiry the fifth failure was not to inform the families that the deaths were being investigated with a view to finding out why they occurred.
The inquiry, chaired by Lady Justice Thirlwall, is expected to sit until early 2025, with findings published by late autumn of that year.