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Could Lucy Letby have been stopped sooner? The missed opportunities to catch a killer revealed

External review into the Countess of Chester hospital – which has not yet been published – expected to find multiple failings, The Independent understands

Rebecca Thomas
Health Correspondent
Monday 21 August 2023 07:59 BST
A look around the Countess of Chester Hospital neonatal unit where Lucy Letby worked

Serial killer nurse Lucy Letby was free to target babies for nearly a year after she murdered her first patient as hospital leaders repeatedly ignored concerns raised by whistleblowers, The Independent has learned.

Staff raised concerns over three “unexplained” baby deaths at the Countess of Chester Hospital in July 2015 but health chiefs failed to investigate the allegations, several hospital insiders have claimed.

Letby’s murderous rampage had started the month before and she went on to target another 14 infants over the next 12 months. The former nurse, 33, has now been found guilty of murdering seven babies and attempting to murder six others – becoming Britain’s most prolific child killer.

An external review into the hospital, set to be published after the trial, is expected to find multiple failures by the trust’s leadership to act on warnings, The Independent understands.

The parents of one baby, Child L, who she attempted to murder with insulin, have also called for a public inquiry into the trust’s failings.

Several hospital sources told The Independent:

  • Doctors alerted managers to three unexplained deaths in July and October 2015 but they were not investigated
  • Staff raised Letby’s presence at a string of suspicious deaths – but hospital executives ignored the issue for three months and two more babies died
  • Another senior medic raised concerns over Letby in a formal meeting with executives in May 2016 but no action was taken
  • Some doctors were said to be “suicidal” because “concerns were not being heard”
  • Trust leaders allegedly told paediatricians not to go to the police because “it will be bad for the trust’s reputation”.
Letby has been convicted of seven counts of murder (AP)

One senior source working at the hospital said: “There was a run of three unusual deaths that happened out of the blue and in babies who were stable.

“There was also one near miss with a baby who had an unexpected, unexplained collapse but recovered. In July 2015, these cases were reviewed, and it was flagged as unusual.”

They added: “Although the association with Letby’s [presence] was seen, nobody was really thinking about somebody causing deliberate harm.”

Months later, in October 2015, doctors flagged to senior managers that “things were continuing to happen” in the neonatal unit with no explanation. But that these were considered to be a “blip”, the source said.

Another source said: “There was that lack of curiosity about examining their death and incident data; it was sitting there for everyone to see.

“Nobody sought to understand it. By the time they got to October 2015, there was enough concerning data in that they had a number of deaths to explain and there was a lack of focus on incidents where babies had collapsed.”

Letby’s presence at time of deaths was noted early on (Chester Standard/SWNS)

Senior doctors carried out a review in February 2016 in which they could find no common medical reason for the unexplained deaths. But they noted Letby was present on each occasion.

A source with knowledge of that review said: “As far as I’m aware, those findings from that high-level review were not acted upon. I don’t think the findings were shared at all.

A second source added: “It was noted that the presence of Letby at all these times was there, but not [again], necessarily accusation of causality.”

Doctors then requested a meeting with the hospital directors to discuss their concerns about the nurse but this did not happen until May, sources said – during which time two babies were murdered.


Several sources described the behaviour of the senior executives – including then chief nurse Alison Kelly – as “protective” and “defensive” when concerns were raised by about the babies’ deaths and Letby’s presence.

In May 2016, after doctors finally met executives, sources claimed no action was taken over Letby with leaders allegedly saying “let’s see how things go”. She remained on frontline duties until June of that year when she was moved to an admin role.

Colleagues at Countess of Chester Hospital struggled to escalate concerns over Letby (AFP/Getty)

An insider said: “Had that meeting with senior executives happened earlier in February 2016 rather than May, things might have been different.”


Throughout 2016, paediatricians continued to raise concerns, with one source describing some doctors as feeling “suicidal because their concerns were not being heard”.

It would not be until a year later in 2017 that doctors claim they were allowed to talk to the police about their concerns over the baby deaths and Letby. She was arrested in July 2018.

One source alleges paediatricians were told by trust leaders in late 2016 – after the babies’ deaths – that if they reported concerns to the police “that’ll be the end of the unit and it will be bad for the trust’s reputation”.

The moment Letby was arrested over the baby deaths (Cheshire Police)

“You can’t mitigate for bad people,” the source continued. “They’re from all walks of life, and they’re very good at hiding in plain sight. But, what you can mitigate for is when these people get spotted, what happens to the people who were trying to blow the whistle and you know, what are the responses of the people from the top?”

Wider failings

Wider concerns were raised about the NHS and trust’s approach to recording baby deaths at the time.

One source said a national database of Sudden Unexpected Death in Childhood was in use but that the babies’ deaths were not recorded under this.

The source said: “It was around then when they should have said ‘babies were dying and near dying here and we don’t know why’. Instead of being open and looking into that, they just blamed the people who were raising the concerns and it’s hard to understand why that is.”

Letby killed several babies while hospital leaders ignored concerns (Cheshire Constabulary)

A review by the Royal College of Paediatrics and Child Health was commissioned by the trust’s medical director Ian Harvey in June 2016 to look at the cluster of deaths.

The report, finished in November 2016 and seen by The Independent, noted there were several areas where the trust failed to properly report neonatal deaths.

It also raised “concerns” that the deaths were not reported or picked up by the child death overview panel, which is a local authority-run service that investigates deaths in hospitals and communities.

The review noted that “staff were distressed over the deaths and affected by the actions taken in response to concerns”.

Several whistleblowers also highlighted a missed opportunity when concerns were raised to the Care Quality Commission which inspected the hospital in February 2016.

Sources said doctors told the CQC they had patient safety concerns and they were not able to get executives to “take them seriously”.

Dr Sean O’Kelly, CQC’s chief inspector of healthcare, said the CQC’s team received concerns from hospital staff about a lack of support from management when they tried to speak up and that inspectors directly highlighted the issue to senior trust staff.

Former chief executive Tony Chambers told The Independent that the February 2016 review did not identify any common themes, although some themes occured in more than one baby, which triggered a meeting with other senior hospital staff.

He said it was highlighted that Letby had been present in more cases than other staff, but he added: “There was no evidence other than coincidence and what was described as ‘gut feeling’.”

He added that there were unusual blood test results after the collapse of Baby L, but concerns were not raised. He said the result “would have materially altered the focus of subsequent inquiries and actions if they had been raised with me or any other senior manager in August 2015”.

Mr Chambers also told The Independent he is not aware the CQC raised any issue with him at the time. He said the serious allegations related directly to Letby were escalated to him for the first time in June 2016 and that action was taken.

Meanwhile, a trust spokesman said: “Since Lucy Letby worked at our hospital, we have made significant changes to our services. I want to provide reassurance that every patient who accesses our services can have confidence in the care they will receive.”

Alison Kelly said in a statement: “It is impossible to imagine the heartache suffered by the families involved and my thoughts are very much with them.

“These are truly terrible crimes and I am deeply sorry that this happened to them.

“We owe it to the babies and their families to learn lessons and I will fully cooperate with the independent inquiry announced.”

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