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Do Statistics Prove Accused Nurse Lucy Letby Innocent?

Updated: Sep 6, 2023


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Statistical analyses, a damning 2016 report by the Royal College of Paediatrics and Child Health (RCPCH), and various other factual inconsistencies in publicly available official documents, may constitute reasonable doubt



Please forgive the personal touch but I have written this post in memory of my Mum who passed away recently and who many years ago was a nurse and midwife. I don't know for certain that Lucy Letby did not commit the crimes of which she is accused (I don't think she did) but, regardless, nurses everywhere should be greatly appreciated and applauded. This post is for them. And my Mum.



As readers of my blog will know, I have an interest in so-called cluster cases - criminal trials where there is an apparently high number of occurrences of some event. For example, 'excess deaths' at a hospital, within a family or among a GP's patients. Or wicked postmasters fiddling books.


In such cases, particularly ones where the evidence is purely circumstantial, a grasp of statistics is critical. Since this is often lacking, whether among judges, jurors or, most worryingly, defence lawyers, there is scope for a miscarriage of justice to occur i.e. for an innocent person to be found guilty.


Where there is a cluster, it is important first to determine the probability of the cluster occurring purely by chance. In the case of 'excess deaths' on a particular hospital ward, this involves considering the probability of the 'excess death' rate occurring somewhere on that type of ward, not on one specific ward. If it is determined that the probability is low, then the cause must be investigated. Also, such investigations can be biased - they may be conducted by those who would be implicated in some way by the true cause of the 'excess deaths' being determined.


The trial, currently underway in Manchester, of Lucy Letby, the neonatal nurse at The Countess of Chester Hospital (COCH) accused of murdering 7 babies and of 15 attempted murders (pertaining to 10 babies) between June 2015 and June 2016 is a cluster case, and one where the evidence is purely circumstantial. The hospital first investigated an elevated number of deaths of very premature babies in February 2016. Almost five years later, in November 2020, Letby was charged, though at first she was charged with 8 murders and 10 attempted murders.


I should make it clear that I do not know if Letby is innocent. How could I? Nor am I going to speculate - what I present in this post are information and data gleaned from publicly available official documents, statistical analyses of said data, and references in the media to official documents, official announcements, court dialogue (all links provided). Finally, and importantly, whether Letby is innocent or not, the parents of the babies that are the subject of the trial have gone through and continue to go through a truly terrible experience.


Below is a list of the various official sources of information and data that I refer to in this post or have read in the course of my research.


Document 1: Royal College of Paediatrics and Child Health (RCPCH) Service Review of the neonatal service at the Countess of Chester Hospital (COCH), dated November 2016 (Link 1: http://allcatsrgrey.org.uk/wp/wpfb-file/rcpch_invited_review_nov_16_final_-for_dissemination-_08_02_17_1_30pm-pdf/, Link 2: https://pdf4pro.com/cdn/www-coch-nhs-uk-7537c.pdf, Link 3: http://www.coch.nhs.uk/media/141843/rcpch_invited_review_nov_16_final_-for_dissemination-_08_02_17_1_30pm.pdf. Note that this last link to the document on COCH's own website now goes to a page that says, "There seems to have been an error, please navigate to the page on the menu above").


Document 2: Care Quality Commission (CQC) Inspection Report, Countess of Chester Hospital NHS Foundation Trust, dated 17 May 2019 (Link: https://api.cqc.org.uk/public/v1/reports/75694247-129f-4e2d-8a12-b2e59d3245ca?20210116074506)


Document 3: Care Quality Commission (CQC) Inspection Report, Countess of Chester Hospital NHS Foundation Trust, dated 15 June 2022 (Link: https://api.cqc.org.uk/public/v1/reports/0257680c-6a9a-49fe-ac39-a5c982f58985?20221129062700)


Document 4: Care Quality Commission (CQC) Inspection Report, Countess of Chester Hospital NHS Foundation Trust, dated 30 September 2022 (Link: https://api.cqc.org.uk/public/v1/reports/85aed0ff-145b-4572-ab44-08bcd3124f78?20221129062700)


Document 5: Number of deaths (monthly) by type (late fetal loss, stillbirth, early neonatal, late neonatal, post neonatal) at the Countess of Chester Hospital NHS Foundation Trust, January 2013 to October 2018 (Freedom of Information Request Link: https://www.whatdotheyknow.com/request/521287/response/1255362/attach/3/FOI%204568.docx?cookie_passthrough=1)


Document 6: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK), Perinatal Surveillance Report, UK Perinatal Deaths for Births from January to December 2015 (Link: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK-PMS-Report-2015%20FINAL%20FULL%20REPORT.pdf)


Document 7: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK), Perinatal Surveillance Report, UK Perinatal Deaths for Births from January to December 2016 (Link: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK%20Perinatal%20Surveillance%20Full%20Report%20for%202016%20-%20June%202018.pdf )



Background/RCPCH service review (Nov 2016)


By way of background, "the Royal College of Paediatrics and Child Health (RCPCH) was invited to review the neonatal service at the Countess of Chester Hospital (COCH) following re-designation [demotion] from level 2 Local Neonatal Unit (LNU) to level 1 Special Care Unit (SCU) in July 2016 due to concerns about increasing neonatal mortality. A number of causes had been postulated but there was no definitive explanation for the trend". This is the opening statement in the Executive Summary of the final copy of the RCPCH report dated November 2016 (hereafter referred to as the 'RCPCH report').


The findings of the RCPCH report were announced to the media in February 2017, along with the report itself. Although it was the hospital itself that downgraded its own neonatal unit, the RCPCH team that visited in September 2016 found significant failings by the unit in relation to reporting, staffing, practices, etc.. The team made various recommendations that it said should be implemented before a reinstatement of the unit as an LNU should be considered.



Missing deaths


The below neonatal deaths data is taken from an official COCH document that was made public as a result of a Freedom of Information request.



According to the RCPCH report, "On 8th February 2016 a half day 'high level' thematic review of ten of the cases took place with the involvement of the ODN clinical lead." (RCPCH report clause 3.7)


Given that the "half day 'high level' thematic review" took place on 8 February 2016, it would appear that the ten cases reviewed were the ten early neonatal deaths from June 2015 to January 2016 in the above table (Table 1.1). Of these ten, Letby was later charged in relation to just three of them. In other words, she could not be connected with seven of them.


Also, she was later charged with two murders in August and October 2015 (Children E and J). But, as can be seen in the table above, there were no deaths recorded in either August or October 2015. The data in the tables above are up to October 2018, so one would assume that there was plenty of time to correct any mistakes i.e. to include the two deaths in August and October 2015.



High incidence of 'non-malicious deaths' (those which Letby has not been charged with)


Letby is accused of murder in relation to 7 of the deaths in 2015 and 2016, but there were 11 for which she has not been implicated (Chart 1) presumably because she could not have been responsible for them (in fact, the defence, in its opening, said that she could not have been responsible for some of the 7 deaths that she has been connected with).


If we assume that 'non-malicious' deaths are distributed according to the Poisson distribution (deaths are independent of each other and occur at a rate of 2.7 per year, the average of 2013, 2014 and 2017), then the odds of there being 11 deaths (the ones Letby has not been accused of) over a two year period purely by chance is 1 in 83. In other words, the prosecution is asking the jury to believe that there is both a serial killer at work as well as some other factor (e.g. faulty equipment, understaffed unit, incompetence among medical staff) causing the deaths. And that these two factors both started and stopped at exactly the same time. Quite a coincidence!


By the way, for those who might be tempted to think the high death rate fell in 2017 (actually it was from mid 2016) because Lucy Letby was "caught", remember that COCH's neonatal unit was downgraded in June 2016 and so no longer was allowed to care for higher risk babies.


Chart 1




In the case of Beverley Allitt, the nurse found guilty in 1993 of murdering four infants, attempting to murder three others, and causing grievous bodily harm to a further six at Grantham and Kesteven Hospital, Lincolnshire, between February and April 1991, roster data (see below) determined (unlike in Letby's case) that she was present at all 25 of the suspicious incidents that were investigated (Allitt was not charged for all of them).


Figure: Roster data in Beverley Allitt case

Source: The Beverley Allitt Tapes (Woodcut Media, Sky Crime documentary)



It should also be noted that Allitt never testified at her trial (according to the Greensboro News and Record, Allitt was not "in court for nine weeks of her 13-week trial because of [an] eating disorder and did not testify. Colleagues and psychiatrists were unable to suggest a motive, and she has made no public statements" (https://greensboro.com/english-nurse-convicted-in-death-of-infant-patients/article_bec86764-b5ed-5bf1-8d5d-719e01ff22db.html). Letby on the other hand chose to testify and spent nine days on the stand being cross examined (you can read all the reports in The Chester Standard and judge for yourself how she did). Furthermore, during the hours of police questioning, Letby did not once invoke her right to silence (again, you can read many of the various exchanges cited at trial in The Chester Standard). This, too, is unlike Allitt, who after a certain point of police questioning refused to say anything further.


Then there is the case of nurse Colin Norris who was convicted in 2008 of murdering four elderly patients and attempting to murder two others in 2002 (his case was recently referred to the Court of Appeals following a scientific finding that hypoglycaemia can have a natural cause and in the elderly often does - according to the prosecution the hypoglycaemia in Norris' 'victims' was due to him having injected them with insulin). Norris was originally charged with five murders, but before trial roster data determined that for one of them he was not present so could not have been responsible. The police then started looking for second murderer, right? Er, no - they just decided that a death that they were previously certain was a murder was not in fact a murder, and reduced the count to four.



High incidence of multiple pregnancies in relation to murder/attempted murder charges


"The obstetricians were confident in their ability to manage high risk pregnancies including twins and triplets to later stages of gestation, and where cots and appropriate safe staffing are available it is preferable for families to be able to stay locally following delivery. The obstetrics team had expressed concern about four of the deaths particularly, which were discussed at the perinatal M&M meeting and found to have no antenatal indicators of concern. The review team was however concerned at whether there were sufficient staff for the LNU to care for triplets, for example, albeit post 34 weeks." (Clause 4.4.14, RCPCH Report)


Chart 2 below shows that the percentage of multiple pregnancies in relation to the murder/attempted murder charges was way higher than in the general population. For example, in the general population, 1.2% of pregnancies are multiple pregnancies. In the case of the pregnancies at COCH where there was a murder charge, 50% were multiple pregnancies (3 of 6). In other words, it may be that the deaths and collapses reflected the high risk nature of multiple pregnancies rather than the presence of a murderer.


Chart 2



Higher activity/lower admission birthweight than average


"Further in-depth analysis by the neonatal lead in July 2016 examined activity and acuity from June 2015. This included admissions per month, time between deaths, total care days per month, IT care days per month, birthweight and prematurity. This was not a systematic review but concluded that there was higher activity and lower admission birthweight than average during the period corresponding to the increase in mortality. This was not however considered to have been significant enough to explain the increase in mortality." (Clause 3.8, RCPCH Report)


I would be interested to know if the term "significant" was used in its strictly statistical sense (i.e. statistical significance). I presume not, because the conclusion appears to be that of the 'neonatal lead', not a statistician. Also, it appears that the higher activity/lower admission birthweight was not considered sufficiently significant because it could not solely explain the increase in mortality. Why could it not have been deemed to have been a contributing factor, one among others? Then, what about nonlinearity? Presumably there is a point at which a small percentage increase in activity/decrease in birthweight leads to a large increase in mortality. To what extent was this considered by the neonatal lead?



Problems with UVCs/new UVC guidance (UVC = umbilical venous catheter)


"Following reflection both individually and in discussions the consultants noted that several of the infants had collapsed unexpectedly and had been surprisingly unresponsive to resuscitation, despite the staff following standard protocols in each case. One surviving infant was mentioned as having needed resuscitation for similar collapses over three nights but subsequently recovered, although the review team did not see details of 'near misses' such as this. The consultants did not initially consider that there were any links between the episodes of collapse in the infants that died but subsequently they began to note similarities. For example some of the infants displayed a sudden mottling appearing after a few minutes of resuscitation, usually starting on the limbs, and on at least one occasion on the central abdomen and chest. The consultants had considered a number of possible causes for this appearance but there remained no definite explanation." (Clause 3.11, RCPCH Report)


If staff "followed standard protocols", why was there a need for new UVC guidance, per clause 3.7? Indeed, there have already been several mentions during the trial of problems with UVCs in relation to a number of the babies, as below. To what extent did the consultants consider that the collapses may have related to the UVC issues? Since it would have been the consultants who inserted the UVCs, might they have preferred to have honed in on Lucy Letby rather than incorrect insertion of the UVCs?


Extract from Chester Standard reports mentioning issues with UVCs:


Nurse Melanie Taylor, who was the designated nurse for Child A on the shift before he died, gave evidence in court to say she had had "no concerns" with him and he was "stable", but issues with a cannula and a UVC meant he was not receiving fluids for a couple of hours that afternoon. https://www.chesterstandard.co.uk/news/23062657.death-baby-lucy-letby-case-came-completely-blue-witness-says/


References to issues with UVCs in other Chester Standard articles reporting on the trial:


A chart shows any 'major events' that took place for Child A. One was UVC lines at 1pm.


Attempts to fit an umbilical vein catheter (UVC) twice failed


An addendum by Miss Taylor just after 7pm recorded the UVC was in the wrong position, and was reinserted, but was still in the wrong position.


The UVC was in the 'wrong position' twice - it had been taken out and re-inserted, but was still in the wrong place. Another option was sought.


Dr Beech said the UVC had come out of Child C during a previous shift


The trainee doctor was called to insert a UVC (a catheter) into Child A on the afternoon of June 8. Following an X-ray, the catheter was "not ideally placed".


The radiology report said, from the x-ray, the ET tube was 'in satisfactory position' following the reintubation, along with the NG tube, while a UVC line required further adjustment.


The UVC was removed as it was 'only able to advance to 5cm'. Dr Rylance says usually "you are expected to advance it much further.


A further note was made to say the UVC 'continued to ooze'.


A second x-ray image of 'effectively the whole body' is shown the court at June 21, 1.32pm. Professor Arthurs notes two features - the 'obvious one' being the UVC going up towards the heart, which has been pushed in too far.


UVC still in situ, but in wrong position



Small number of deaths in 2016


According to the 2016 MBRRACE-UK (Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries) Perinatal Mortality Surveillance Report, the number of neonatal deaths at COCH in 2016 was low ("entry suppressed because of small number of deaths"), per the below screenshots. And yet according to the hospital data presented above, deaths in 2016 were high. The discrepancy is puzzling and in view of everything should be investigated.

Source: MBRRACE-UK Perinatal Mortality Surveillance 2015 and 2016 Reports



Dr Dewi Evans


Dr Dewi Evans was one of the medical experts called by the prosecution.


Asked at the trial on 14 October 2022 by prosecution barrister Mr Myers if he was being 'an expert' in being 'an expert witness', Dr Evans replied: "I think that's far too flash for me. My role is to assist the court on some extremely challenging issues. I call myself an independent medical witness, not an expert."


And yet on Dr Evan's LinkedIn profile (below) he states that he provides "expert medical advice".




Below is an excerpt from The Chester Standard's report of the trial on Thursday, 9th February, 2023.


A REPORT from expert witness Dr Dewi Evans in an unrelated civil case was described as “worthless” by a senior judge, jurors in the trial of Lucy Letby have heard. Retired consultant paediatrician Dr Evans has been called by the prosecution to give his opinions as to why a number of babies suffered collapses at the Countess of Chester’s neo-natal unit. On Thursday, Manchester Crown Court was told Dr Evans was criticised over his involvement in an application for permission to appeal against a care order involving two children – in a case unconnected to Letby. Dr Evans supported the parents’ desire to have increased access to the children who were being cared for by their grandparents, the court heard. Refusing permission last December, Court of Appeal judge Lord Justice Jackson said Dr Evans’ report was “worthless” and “makes no effort to provide a balanced opinion”. He went on: “He either knows what his professional colleagues have concluded and disregards it or he has not taken steps to inform himself of their views. Either approach amounts to a breach of proper professional conduct. No attempt has been made to engage with the full range of medical information or the powerful contradictory indicators. Instead the report has the hallmarks of an exercise in ‘working out an explanation’ that exculpates the applicants. It ends with tendentious and partisan expressions of opinion that are outside Dr Evans’ professional competence and have no place in a reputable expert report. For all those reasons, no court would have accepted a report of this quality even if it had been produced at the time of the trial.”




Below are some interesting excerpts from the RCPCH report that was published and given to the media in February 2017


"Since June 2015 the paedriatric consultants have become concerned about a higher than usual number of neonatal deaths on the unit, several of them being apparently 'unexplained' and 'unexpected'. Most of these infants had post-mortem examinations, all cases had been reviewed by the mortality and morbidity meeting (M&M), and one had undergone a Root Cause Analysis review, with some also being examined by obstetric secondary review. On 8th February 2016 a half day 'high level' thematic review of ten of the cases took place with the involvement of the ODN clinical lead. A summary internal review of the nursing observations, staffing and junior doctor rotas for the 12 hours before the deaths was then conducted. No definite causal correlation was identified between the various cases, however a number of recommendations (such as new UVC guidance) resulted from the high level review." (RCPCH clause 3.7)


Comment: There were various mentions of issues in relation to fitting of UVC in both the RCPCH report and at trial (more detail earlier in this post).


"Where neonates may require surgery (e.g. swollen abdomen) there is some confusion about the protocol with some clinicians contacting the surgical team at Alder Hey immediately, and others talking through the situation with the neonatologists in LWH or Arrowe Park first. These pathways were explored in a surgical review in April 2016 which made six recommendations for service providers and five for the network including a communication improvement plan and a single surgical model to reduce confusion and delays." (RCPCH clause 3.7)


Comment: "confusion about the protocol" among clinicians sounds concerning


"Most of the consultants had been on duty for at least one of the deaths. Further in-depth analysis by the neonatal lead in July 2016 examined activity and acuity from June 2015. This included admissions per month, time between deaths, total care days per month, IT care days per month, birthweight and prematurity. This was not a systematic review but concluded that there was higher activity and lower admission birthweight than average during the period corresponding to the increase in mortality. This was not however considered to have been significant enough to explain the increase in mortality." (RCPCH clause 3.7)


Comment: Why were higher activity and lower birthweight not considered to have been significant enough to explain the increase in mortality? Presumably the relationships (between activity/birthweight and mortality) are not linear i.e. above a certain activity or below a certain birthweight, mortality increases non linearly (perhaps exponentially). Furthermore, witnesses at the trial talked about 'very high number' of admissions.


"Following reflection both individually and in discussions the consultants noted that several of the infants had collapsed unexpectedly and had been surprisingly unresponsive to resuscitation, despite the staff following standard protocols in each case. One surviving infant was mentioned as having needed resuscitation for similar collapses over three nights but subsequently recovered, although the review team did not see details of 'near misses' such as this. The consultants did not initially consider that there were any links between the episodes of collapse in the infants that died but subsequently they began to note similarities. For example some of the infants displayed a sudden mottling appearing after a few minutes of resuscitation, usually starting on the limbs, and on at least one occasion on the central abdomen and chest. The consultants had considered a number of possible causes for this appearance but there remained no definite explanation." (RCPCH clause 3.8)


Comment: If staff followed standard protocols, why was there a need for new UVC guidance? Also, Letby was only charged in relation to seven of the fourteen deaths from June 2015 to June 2016. What about the other seven, which would still have constituted an unusually high number? Why wasn't Letby charged in these cases?


"In response to this allegation and the high acuity and activity on the unit the Medical Director, Nursing Director and Trust Board decided on 7th July to reduce the designation of the service to a Special Care Unit (SCU) caring for infants from a minimum of 32 weeks gestation pending an external review by the RCPCH, and the change appeared to have been handled sensitively and effectively by management with good network and public engagement." (RCPCH clause 3.9)


Comment: It is far from clear in the RCPCH report to what "this allegation" refers but it seems to be an allegation that the elevated number of deaths were the result of harm. However, the decision to downgrade was also due to the high acuity and activity on the unit. In other words, it seems to be quite a coincidence that the elevated number of deaths was due to both harm having been inflicted and high acuity/activity.


"Two of the cluster of deaths were not reported; the current policy indicates that not all deaths need to be submitted as DATIX, if they are "expected deaths", and in 2015-6 only 10 of the 13 deaths were reported as incidents on the neonatal incidents summary. The definition of 'expected' was not available but presumed to be that used in safeguarding/child death panels and it was not clear who is responsible for DATIX entry. Other areas in the hospital report well but the neonatal unit have for some time apparently been less systematic in reporting." (RCPCH clause 4.4.5)


Comment: Reporting protocols were clearly not followed which is alarming


"There are however significant gaps in both medical and nursing rotas" (RCPCH report Executive Summary)


"The arrangements for investigating neonatal deaths must be strengthened; review findings appear to be reported at several different meetings but it is unclear at which the resulting actions are monitored. Despite sound structures, there seems to be disconnection between the neonatal leadership and the Trust's governance and risk management processes. Reviews highlighted examples of poor decision making, delays in seeking advice, and delayed retrieval of infants to tertiary units." (RCPCH report Executive Summary)


"The physical separation of the tertiary centres and lack of tight protocols for transfer to them remains a risk as is the commissioner indecision around integration of the three network transport services, leaving an under-resourced, single clinical transport team in Cheshire and Merseyside." (RCPCH report Executive Summary)


"The service…is non-compliant on nurse and medical staffing levels, environment and accommodation for parents, support from the community neonatal team and postnatal follow-up." (RCPCH report clause 4.1)


"The paediatrics team has self-assessed against the 2015 'Facing the Future' standards for acure paediatric care, and stated complaince with all standards except the first - consultant presence at times of peak activity. There has been a 'hot week' system since 2008-9 but a single consultant is insufficent to safely cover both the paediatric and neonatal wards." (RCPCH report clause 4.1.5)


"There is insufficient storage space resulting in many pieces of equipment being stored in corridors. Direct visibility from one area to another is poor, and infants are moved regularly to accommodate acuity - an extra risk in the system." (RCPCH report clause 4.1.6)


"BAPM standards suggest that an annual report should be prepared for each neonatal unit. No such report had been produced for COCH due, presumably, to pressure of activity so this valuable opportunity for influence had been lost." (RCPCH report 4.1.7)


"The paediatric service (including neonates) struggles to fill its Tier 2 (middle grade) posts and medical staffing numbers are inadequate for a Tier 2 LNU, although sufficient for a Level 1 SCU." (RCPCH report 4.2)


"Although…on-paper compliant…there are only two scheduled consultant ward rounds per week on the neonatal unit, yet five on the paediatric wards. This would not meet training requirements or RCPCH and BAPM guidance for a LNU." (RCPCH report 4.2.1)


"The investigation reports from the infant deaths showed a pattern of insufficient senior cover and a reluctance to seek advice. Given the acuity of the unit (pre 7th July) there should have been a greater level of consultant presence on the ward." (RCPCH report 4.2.2)


"The review team was not aware of any strategic plans to stabilise the Tier 2 rota such as development of ANNPs or appointment of specialty grade doctors, despite an annual agency cost of around £125k. In one of the cases the nurses had expressed concern about the capability of the locum registrar whose agency had previously been advised not to offer the doctor to the Trust again. The nurses took steps to ensure the consultant was aware but it was not clear to the Review team that the locum recruitment process was sufficiently robust for such a situation not to recur and no learning/action was documented for this case." (RCPCH report 4.2.4)


"There are however no ANNPs [at either Tier 1 or Tier 2 level." (RCPCH report 4.2.7)


"The CQC indicated that neonatal staffing was of concern, requiring the Trust to "Ensure staffing levels are maintained in accordance with national professional standards on the neonatal unit and paediatric ward" but the detail of what this meant was not available in the public domain and no other concerns were raised in their report. The nurses on the unit were also supporting transitional care in the maternity unit and administration of antibiotics for infants from Cestrian Ward which depleted their availability for sick infants in the LNU." (RCPCH report 4.2.10)


"In terms of acuity network data available to the team had indicated that COCH has a significantly higher proportion of late gestation admissions (over 37 weeks) than other local units - 10.73% compared with 5.69% average for the 22 units, and this had been raised for several years. The 2015-6 data available in October showed the figure had fallen to 7.8%, lower than the other two units in the region. A number of possible reasons for the higher level had been suggested including the transitional care arrangements, differences in obstetric approach, reluctance to discharge, low thresholds to transfer in or inexperienced medical staff but the increasing trend towards the network norm was commendable and should continue." (RCPCH report 4.2.11)


"There were however some historical issues around senior level decision making. Some nurses reported that external escalation was not always as timely as it could have been, and nurses did not feel empowered to participate. Although the nurses work to a relatively traditional model, they reported that they will support escalation more "vigorously" depending upon which consultant or locum is on duty. Relationships are starting to improve although recent events around the reconfiguration had damaged relationships between senior nursing staff and the consultants and thus may need active intervention to restore trusting working relationships." (RCPCH report 4.3.2)


"Leadership at senior Trust level appeared to be somewhat remote from the day to day issues taking place in the unit and representation on key decision making network groups was sometimes at a very high level with delays in feeding back to the operational team." (RCPCH report 4.3.7)


Comment: On 20 September 2018 it was reported that COCH chief executive Tony Chambers had resigned (https://www.nationalhealthexecutive.com/News/trust-chief-executive-resigns-amidst-infanticide-investigation/211926). Chambers had been chief executive since 2012 and so was at the helm during the period of elevated deaths in 2015 and 2016.


"Although the ward can be really busy, everyone wants to progress, but the nurses felt there had been a dip in morale since the changes and information about the temporary reconfiguration had not been shared, even with the Band 6 nurses who had to manage the enquiries from anxious parants over the weekend following the announcement. Mention of installing CCTV on the unit without explanation had unsettled the nursing team further although the Unit Manager had strived to reassure them." (RCPCH report 4.3.8)


"Until early 2016 there was a Risk and Patient Safety Lead but the role was redesigned when she left the Trust (around the time of the CQC visit) and the post of Risk Midwife was established and filled in May." (RCPCH report 4.4.6)


"The review of deaths carried out by the (neonatal lead) consultants that, together with two additional deaths, triggered the unit's reconfiguration in July 2016 did not use a recognised RCA process nor did it involve the governance lead/risk manager. The staffing grid in particular was not validated." (RCPCH report 4.4.8)


"The RCPCH review team recommends that the death/near miss reviews process requires further strengthening and follow corporate process." (RCPCH report 4.4.9)


"The review team was concerned that it was only when the data was formally reviewed by the analyst did management realise how busy the unit was; this had not been raised as a risk since the neonatal team had just continued to work harder." (RCPCH report 4.4.12)


"Not all of the caes underwent a post mortem despite this being recommended in BAPM 2011." (RCPCH report 4.4.13)


"The review team was however concerned at whether there were sufficient staff for the LNU to care for triplets, for example, albeit post 34 weeks. (RCPCH report clause 4.4.14)


"The RCPCH review team was concerned that the CDOP did not appear to be alert to the cluster of neonatal deaths, and for at least some there should have been a Rapid Response Meeting within 5 working days of notification. If the cause of death is not not clear then no death certificate can be written and the case must be referred to the coroner. (Recommendation: The CDOP should consider whether its processes could have detected the cluster of deaths and initiated external review more swiftly)." (RCPCH report 4.4.25)


"All those the review team spoke to told us that there are significant capacity pressures on the Cheshire and Merseyside Neonatal Transfer service, which contribute to delays in transferring infants out promptly." (RCPCH report 4.5.1)


"There were several reports that the doctors will wait too long before escalating concerns about an infant, both from junior to consultant and also to the network and when they do seek tertiary level advice, the transport team is not informed sufficiently early to be on 'standby'. Consequently when a decision to transfer is made, there may be further delay as the transport crew and an appropriate vehicle are mobilised. If the team is on another retrieval or undertaking a 'park and ride' surgical engagement then either the transfer must wait or another team mobilised from elsewhere in the network. With the Cheshire and Merseyside transport team having no 'out of hours' administrator to mange the cot bureau function it is incumbent on the referring clinician to identify and mobilise an alternative team. Since the re-designation of the unit there were reports that the consultants can spend up to 4 hours trying to find an available cot and retrieval team due to the increased demand for transfers. This is an unacceptable waste of senior medical time, and should be raised as an incident on DATIX. Other services in the UK create a 'conference call' so those giving advice and those on the transport team are aware of the status of infants which may require transfer. (Recommendation: Ensure tertiary advice calls include an 'early warning' or conference call to the transport team to enable better planning and deployment of the crew)." (RCPCH report 4.5.2)


"COCH is the busiest non-NICU in the C&M network, with 4800 cot days (3773/79% of which were SC/TC days). Analysis by the network of cot numbers and activity in its annual report had identified COCH as an outlier with over-provision of IC cots and under-provision of SC cots." (RCPCH report 4.5.7)


"The network's 'top table' review in January of a death in October 2015 was reported to have triggered improved data collection across other units, and another death in December 2015 also exposed inadequate liaison between COCH clinicians and the transport team. There appears to be no formal mechanism or process for joint M&M review across the network for infants who have been transferred between units and no mechanism to trigger closure of a unit when it has reached capacity." (RCPCH report 4.5.9)


"The COCH works naturally with Arrowe Park NICU and is considering working more closely together (see 3.14). Where neonates may require surgery (e.g. swollen abdomen) there is some confusion about the protocol with some clinicians contacting the surgical team at Alder Hey immediately, and others talking through the situation with the neonatologists at LWH or Arrowe Park first. These pathways were explored in a surgical review in April 2016 which made six recommendations for service providers and five for the network including a communication improvement plan and a single surgical model to reduce confusion and delays." (RCPCH report 4.5.10)


"The unit took 11% of network admissions but experienced 13% of the deaths in 2015. The consultants had explored a number of factors themselves but not in a systematic way nor following sound governance and root cause analysis processes, and the involvement of the network clinical governance group had been relatively supervisory, working on the summaries of cases rather than examining each in detail." (RCPCH report 4.6.1)


"A number of recommendations have been included in this report which draw out areas of non-compliance with standards or where practice might have improved. To summarise: - Staffing levels are inadequate when mapped to the actual activity and acuity of a LNU under the BAPM standards, both from a nursing and a medical perspective. -Escalation of concerns to tertiary units for advice or transport was sometimes delayed and network agreement to encourage a lower threshold for escalation and discussion is required. - Most of the infants had undergone a Post Mortem from one of the three perinatal pathologists at Alder Hey but these did not include systematic tests for toxicology, blood electrolytes or blood sugar since the infants died in hospital. - In order to thoroughly examine the issues detailed case review of all the deaths (prioritising the unexpected deaths) should be conducted by an independent expert. The personnel issues cannot be resolved formally until this is completed." (RCPCH report 4.6.2)




June 2022 Care Quality Commission (CQC) Inspection Report


On 15 June 2022, six years after the Letby was alleged to have committed her last murder/removed from duty, the BBC published an article titled "Countess of Chester Hospital maternity services unsafe" (https://www.bbc.co.uk/news/uk-england-merseyside-61808681).


This was in response to the Care Quality Commission (CQC) publishing its Inspection Report of Countess of Chester Hospital NHS Foundation Trust, dated 15 June 2022, of an unannounced inspection in February and March in the same year (https://api.cqc.org.uk/public/v1/reports/0257680c-6a9a-49fe-ac39-a5c982f58985?20221129062700).


Below is the article (underlining mine).


A hospital has been ordered to make urgent improvements after a damning inspection found its maternity unit was unsafe.

The department at Countess of Chester Hospital was found to have a dangerous lack of staff and suitable equipment, the Care Quality Commission said. The hospital also scored the lowest rate nationally for staff morale, inspectors found. Bosses said they were "working hard" to make improvements. Countess of Chester Hospital NHS Foundation Trust remains rated as requires improvement overall. The unannounced inspection in February and March was prompted by concerns about the quality of care in certain areas. It covered medical care, surgery, maternity care and urgent and emergency services, as well as leadership. Inspectors found several failings at the maternity unit. Notably there were not enough staff with the right qualifications or skills to keep women and babies safe, or suitable equipment. The report also said the trust did not learn from compromised safety incidents to avoid them happening again. It said between April and November last year five patients had major haemorrhages after giving birth at the hospital, resulting in a need for unplanned hysterectomies. Not all those incidents were reported as serious and action plans were not completed quickly, the CQC said, and one patient's lifesaving surgery was delayed as there was no hysterectomy kit in that part of the hospital. Staff morale was said to be the lowest at any NHS trust in the country with some staff saying there was a culture of bullying and discrimination, while not all staff felt respected, supported and valued, inspectors said. High waiting times were also highlighted, with just 13% of patients showing symptoms of breast cancer being seen within two weeks, when the national target is 93%. Inspectors did find staff were caring and knew how to protect patients from abuse, while the urgent and emergency services were able to maintain a "good" rating. Karen Knapton, the CQC's head of hospital inspection, said the trust had "work to do to ensure people consistently receive the safe and effective care they have a right to expect". "We recognise NHS services are under enormous pressure," she said. "However, senior leaders must be visible and have good oversight to manage and mitigate challenges and risks - and we found this was lacking." Trust chief executive Dr Susan Gilby, said work was under way to address "key areas for further improvement". "In our maternity department, we have implemented and are continuing to develop measures to ensure we can consistently provide patients with the safe and effective care they have a right to expect," she said. Dr Gilby said the hospital also wanted to recognise "the work which has taken place to embed a culture of compassionate care and treatment across services".






The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.


© Chimp Investor Ltd



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