A BIZARRE hospital decision could prove baby killer nurse Lucy Letby was being used as a scapegoat for overall failings, an expert has told The Sun.
The neonatal ward at Countess of Chester Hospital (COCH) was experiencing a major spike in premature infant deaths in 2015, which tailed off dramatically when it was stopped from receiving the highest risk patients the following summer.
Monster Letby, 35, is serving a whole life order in prison for the murder of seven infants and the attempted murder of seven more at COCH between June 2015 and June 2016.
Professor Richard Gill, a statistical misrepresentation consultant who has of two other nurses, is convinced convicted murderer Letby was an unlucky scapegoat.
He is among an increasing number of supporters who believe Letby to be innocent, - although many others, including the victims’ families, have blasted the campaign to free her.
He believes the failure to move such patients to more suitable hospitals could prove vital in any potentially successful appeal against her convictions.
And thinks clinical audits being undertaken could be a reason why Liverpool Women’s Hospital did not take them, despite its neonatal unit being graded much higher.
COCH’s Neonatal Intensive Care Unit was graded at level 2 at the time. Guidelines generally advise any such facility treating the most seriously ill babies should be at level 3.
In fact, COCH’s neonatal unit was downgraded again to level 1 by hospital management in July 2016, “due to concerns about increasing neonatal mortality”, ahead of an inquiry by the Royal College of Paediatrics and Child Health (RCPCH).
The unit’s lead neonatologist, Dr Stephen Brearey, had asked management to remove killer Letby from clinical duties the previous month, pending an investigation into her conduct.
She wouldn’t be arrested until 2018. Dr Breary was suspicious of the nurse in 2015 and accused the hospital of negligence for ignoring his concerns, according to reports in 2023.
The downgrade limited the premature babies that it took into its care to those born at 32 weeks’ gestation or over, an age where the medical complications and risks were much lower.
And, as a result, the spike in baby deaths also tailed off - pointing to overall inability to provide complex care properly being a reason for deaths and not a single nurse, claims Prof Gill.
Seven of the babies Letby was convicted of murdering or attempting to murder were either a twin or a triplet, all extremely ill and at higher risk of complications, and so ideally in need of complex level 3 care.
Speaking to The Sun, Prof Gill said the babies should have been “transferred immediately” to a more specialised environment, including that at Liverpool Women’s Hospital (LWH), where some had initially been monitored during pregnancy.
“It was hopeless,” he said. “Chester was receiving babies that should have been born at a level 3 hospital. The doctors there did not have the experience.”
Prof Gill said it is not clear why the babies were admitted to or remained at COCH.
Two of the seven babies Letby was convicted of murdering - Child O and Child P - were from a brood of extremely rare identical triplets whose mum had received at least some antenatal care at LWH before giving birth at COCH.
According to medical summaries, released post-trial as part of an independent expert review, some appeared to be developing issues that only multiple babies sharing a single placenta experience, in that the blood was not being shared evenly to each sibling during the pregnancy, called twin-to-twin transfusion syndrome (TTTS).
“It puts them at incredibly high risk,” said Prof Gill.
He described LWH as “one of the best places in the world to have twins and triplets”, adding: “Why did the doctors allow that mother to have those babies at Chester? They should not have been born there.”
Last year, the Thirlwall Inquiry investigated issues at the hospital during the period of Letby’s spree to determine if management could have done more to stop her crimes.
In the lead up to the probe, reports of concerns about the alarming shortcomings at COCH included unusually high death rates on the neonatal unit, as well as understaffed and under skilled staff, and a unit “out of its depth”, The Guardian reported as part of its own investigation.
In a transcript from the Thirlwall Inquiry, led by senior court of appeal judge Lady Justice Thirlwall, a witness statement from the mum of triplets O and P, as well surviving brother R, said she was only told she was having triplets in the 12th week of her pregnancy.
She was scanned at COCH as it was “more convenient” for her, but was then referred to LWH by her consultant for a second scan - though they were happy to care for her at COCH long-term, adding: “They could refer back to LWH if there were any problems along the way.”
The mum went on say: “At LWH I was told that one of the triplets was a little smaller than the other two, and as all three triplets were sharing one placenta.
“I was given the option of having the smaller triplet’s heartbeat stopped to give the two others a better chance of survival. We decided against this and to let things be.”
She added: “I did not actually expect our babies to be born at COCH, I was explicitly told throughout my pregnancy that they would be born there only if there was a nurse and a bed for each baby.
“I was told that for this reason, it was very unlikely that I would actually have them at the COCH. I was warned by consultants that it was likely that we would have to travel to another hospital.
“We were told that this could be Birmingham or London, but we had to be ready to go anywhere.”
However, the mum said it was only when she went into labour that she was told she would be giving birth at COCH, being assured “there were enough nurses and beds” to deliver her babies.
She said consultant obstetrician and gynaecologist Jim McCormack assured her she would be able to look around the hospital’s neonatal unit, but “in the event” this was “put off and I was not given the opportunity to look around and see the unit”.
“We were told that the probability of us being there would be low.
“That said, we had not experienced a Neonatal Unit before so we had nothing to compare it with anyway.
“I was given to understand throughout my pregnancy that on delivery the babies would need to go to the Neonatal Unit as a precaution due to the risk factors that come with a triplet pregnancy and them having to be born at 34 weeks.”
When she started having contractions at home she was rushed to COCH but described how, despite her condition, she had to walk from the observation room to the labour ward to theatre to undergo a cesarean section - even asked to climb into bed herself.
The mum added it was “very disappointing” that Dr McCormack, who had performed all of her scans, was on holiday and unable to deliver her babies.
She was awake during the delivery, which she described as feeling “very rushed”, and at one stage, after being cut open, she could feel pain.
She described how “blood and fluid splattered up” onto the screen, the wall behind her and “onto my face”.
At one stage, she said it was hurting but was told “I don’t think that is hurting, it’s pulling”.
Later in her statement, the mum described doctors initially had “no concerns” about the babies, despite being so premature, and recalls Letby looking after two of them and showing her partner how to feed all three triplets.
“She told us how lucky we were and that their weights were great,” she added. Letby also showed the mum how to “express milk”, and added her babies were separated as there was a shortage of beds in the neonatal unit.
While staying in the maternity ward, the mum was told by a doctor Child O needed breathing support and she was taken to neonatal unit to see him.
“We were confronted with a scene of complete chaos. It was madness,” she said. “Nurses were running around left and right grabbing medicines and IVs.
“As soon as I went in, I knew it was an issue with one of the boys. When Doctor U saw what was going on, it was obvious he didn’t have any idea what was happening and I could see in his face that he was panicked and shocked.”
She added: “It was clear Child O’s collapse was a complete shock to them.”
The mum said Letby was on the ward at the time and was handing doctors medicine. Child O died later that evening, and his brother Child P, died the following afternoon.
During Letby’s trial, it was heard the father of the triplets “begged” doctors to transfer his surviving son to LWH and they eventually agreed, and his health quickly recovered.
Earlier this year, an international panel of neonatologists and paediatric specialists and told reporters bad medical care and natural causes were the reasons for the collapses and deaths.
Their evidence has been passed to the Criminal Cases Review Commission (CCRC), which investigates potential miscarriages of justice, and Letby’s legal team hopes her case will be referred back to the Court of Appeal.
Neena Modi, Professor of neonatal medicine at Imperial College London, was part of the panel and told The Guardian in February Chester’s neonatal unit was “not staffed or equipped to deal with the most seriously ill babies”.
She went on to say: “What transpired was that the consultants and other neonatal staff were faced with having to provide care for complex neonatal cases outside their experience.
“Their contemporaneous notes in the babies’ case records reveal errors in the recognition of problems and their management.”
Around the time of the Letby crimes, Prof Gill told The Sun some mothers going through high-risk pregnancies would have also been part of clinical audits and trials at various hospitals, including testing the now-standard usage of laser treatment “to fix the blood flow” in a uterus carrying multiple babies at risk of TTTS.
In LWH’s Quality Report 2015-2016, it states: “During 2015-16 Liverpool Women’s NHS Foundation Trust participated in 100% of national clinical audits and 100% of national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.”
It added: “The total monetary value of the income in 2015-16 conditional upon achieving quality improvement and innovation goals was £1,977,598. The monetary total for the associated payment in 2014-15 was £1,955,007.”
It is unclear if any of the triplets, or Letby’s other victims, saw their treatment directly impacted due to any kind of clinical audit or procedures, which would include the much-publicised National Maternity and Perinatal Audit.
But it’s possible that, any one of these may have impacted how many high risk pregnancies were dealt with at Liverpool, claims Prof Gill.
In June 2015, the same month as the first deaths in Letby’s rampage, MBRRACE-UK, the national body which collects data on perinatal mortality, showed LWH had made significant strides in reducing stillbirth and neonatal mortality rates.
Specifically, their stillbirth rate was rated 10% below the national average.
Prof Gill went on to say: “If you have twins or triplets who have a very poor outlook then you might prefer that they died somewhere else.
“Now that’s a very serious allegation, I don’t think that. I mention it, and one might think that.
“I would rather think that out of some rules in their protocol that they were reserving beds for patients they could treat because that would give them good results.
“As a consequence, more babies got treated elsewhere than usual. I’m sure there is an honest explanation for that. But it is really weird.”
He added: “My feeling is this would all need to be looked into if Lucy Letby is ever exonerated and there is an inquiry into what went wrong.”
A spokesperson 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.”
NHS England did not wish to comment when approached.
The Sun has also contacted Liverpool Womens NHS Foundation Trust but had not received a response before publication.
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