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Statistical analyses, a damning 2016 report by the Royal Faculty of Paediatrics and Baby Well being (RCPCH), and numerous different factual inconsistencies in publicly accessible official paperwork, might represent affordable doubt
Please forgive the non-public contact however I’ve written this publish in reminiscence of my Mum who handed away lately and who a few years in the past was a nurse and midwife. I do not know for sure that Lucy Letby didn’t commit the crimes of which she is accused (I do not assume she did) however, regardless, nurses all over the place ought to be tremendously appreciated and applauded. This publish is for them. And my Mum.
As readers of my weblog will know, I’ve an curiosity in so-called cluster instances – legal trials the place there may be an apparently excessive variety of occurrences of some occasion. For instance, ‘extra deaths’ at a hospital, inside a household or amongst a GP’s sufferers. Or depraved postmasters fiddling books.
In such instances, notably ones the place the proof is solely circumstantial, a grasp of statistics is vital. Since that is usually missing, whether or not amongst judges, jurors or, most worryingly, defence legal professionals, there may be scope for a miscarriage of justice to happen i.e. for an harmless particular person to be discovered responsible.
The place there’s a cluster, it is crucial first to find out the chance of the cluster occurring purely by probability. Within the case of ‘extra deaths’ on a specific hospital ward, this entails contemplating the chance of the ‘extra dying’ fee occurring someplace on that kind of ward, not on one particular ward. Whether it is decided that the chance is low, then the trigger have to be investigated. Additionally, such investigations might be biased – they might be carried out by those that can be implicated indirectly by the true explanation for the ‘extra deaths’ being decided.
The trial, at the moment underway in Manchester, of Lucy Letby, the neonatal nurse at The Countess of Chester Hospital (COCH) accused of murdering 7 infants and of 15 tried murders (pertaining to 10 infants) between June 2015 and June 2016 is a cluster case, and one the place the proof is solely circumstantial. The hospital first investigated an elevated variety of deaths of very untimely infants in February 2016. Virtually 5 years later, in November 2020, Letby was charged, although at first she was charged with 8 murders and 10 tried murders.
I ought to make it clear that I don’t know if Letby is harmless. How might I? Nor am I going to invest – what I current on this publish are data and information gleaned from publicly accessible official paperwork, statistical analyses of stated information, and references within the media to official paperwork, official bulletins, court docket dialogue (all hyperlinks offered). Lastly, and importantly, whether or not Letby is harmless or not, the mother and father of the infants which are the topic of the trial have gone by means of and proceed to undergo a really horrible expertise.
Beneath is an inventory of the varied official sources of data and information that I seek advice from on this publish or have learn in the middle of my analysis.
Doc 1: Royal Faculty of Paediactrics and Baby Well being (RCPCH) Service Assessment of the neonatal service on the Countess of Chester Hospital (COCH), dated November 2016 (Hyperlink 1: http://allcatsrgrey.org.uk/wp/wpfb-file/rcpch_invited_review_nov_16_final_-for_dissemination-_08_02_17_1_30pm-pdf/, Hyperlink 2: https://pdf4pro.com/cdn/www-coch-nhs-uk-7537c.pdf, Hyperlink 3: http://www.coch.nhs.uk/media/141843/rcpch_invited_review_nov_16_final_-for_dissemination-_08_02_17_1_30pm.pdf. Observe that this final hyperlink to the doc on COCH’s personal web site now goes to a web page that claims, “There appears to have been an error, please navigate to the web page on the menu above”).
Doc 2: Care High quality Fee (CQC) Inspection Report, Countess of Chester Hospital NHS Basis Belief, dated 17 Could 2019 (Hyperlink: https://api.cqc.org.uk/public/v1/experiences/75694247-129f-4e2d-8a12-b2e59d3245ca?20210116074506)
Doc 3: Care High quality Fee (CQC) Inspection Report, Countess of Chester Hospital NHS Basis Belief, dated 15 June 2022 (Hyperlink: https://api.cqc.org.uk/public/v1/experiences/0257680c-6a9a-49fe-ac39-a5c982f58985?20221129062700)
Doc 4: Care High quality Fee (CQC) Inspection Report, Countess of Chester Hospital NHS Basis Belief, dated 30 September 2022 (Hyperlink: https://api.cqc.org.uk/public/v1/experiences/85aed0ff-145b-4572-ab44-08bcd3124f78?20221129062700)
Doc 5: Variety of deaths (month-to-month) by kind (late fetal loss, stillbirth, early neonatal, late neonatal, publish neonatal) on the Countess of Chester Hospital NHS Basis Belief, January 2013 to October 2018 (Freedom of Info Request Hyperlink: https://www.whatdotheyknow.com/request/521287/response/1255362/connect/3/FOIpercent204568.docx?cookie_passthrough=1)
Doc 6: Moms and Infants: Decreasing Danger by means of Audits and Confidential Enquiries throughout the UK (MBRRACE-UK), Perinatal Surveillance Report, UK Perinatal Deaths for Births from January to December 2015 (Hyperlink: https://www.npeu.ox.ac.uk/belongings/downloads/mbrrace-uk/experiences/MBRRACE-UK-PMS-Report-2015percent20FINALpercent20FULLpercent20REPORT.pdf)
Doc 7: Moms and Infants: Decreasing Danger by means of Audits and Confidential Enquiries throughout the UK (MBRRACE-UK), Perinatal Surveillance Report, UK Perinatal Deaths for Births from January to December 2016 (Hyperlink: https://www.npeu.ox.ac.uk/belongings/downloads/mbrrace-uk/experiences/MBRRACE-UKpercent20Perinatalpercent20Surveillancepercent20Fullpercent20Reportpercent20forpercent202016percent20-%20Junepercent202018.pdf )
Background/RCPCH service assessment (Nov 2016)
By means of background, “the Royal Faculty of Paediactrics and Baby Well being (RCPCH) was invited to assessment the neonatal service on the Countess of Chester Hospital (COCH) following re-designation [demotion] from degree 2 Native Neonatal Unit (LNU) to degree 1 Particular Care Unit (SCU) in July 2016 attributable to issues about growing neonatal mortality. A lot of causes had been postulated however there was no definitive clarification for the development”. That is the opening assertion within the Government Abstract of the ultimate copy of the RCPCH report dated November 2016 (hereafter known as the ‘RCPCH report’).
The findings of the RCPCH report had been introduced to the media in February 2017, together with the report itself. Though it was the hospital itself that downgraded its personal neonatal unit, the RCPCH group that visited in September 2016 discovered important failings by the unit in relation to reporting, staffing, practices, and so on.. The group made numerous suggestions that it stated ought to be applied earlier than a reinstatement of the unit as an LNU ought to be thought-about.
Lacking deaths
The under neonatal deaths information is taken from an official COCH doc that was made public on account of a Freedom of Info request.
Supply: COCH, https://www.whatdotheyknow.com/request/521287/response/1255362/connect/3/FOIpercent204568.docx?cookie_passthrough=1
In line with the RCPCH report, “On eighth February 2016 a half day ‘excessive degree’ thematic assessment of ten of the instances occurred with the involvement of the ODN medical lead.” (RCPCH report clause 3.7)
On condition that the “half day ‘excessive degree’ thematic assessment” occurred on 8 February 2016, it could seem that the ten instances reviewed had been the ten early neonatal deaths from June 2015 to January 2016 within the above desk (Desk 1.1). Of those ten, Letby was later charged in relation to simply three of them. In different phrases, she couldn’t be linked with seven of them.
Additionally, she was later charged with two murders in August and October 2015 (Youngsters E and J). However, as might be seen within the desk above, there had been no deaths recorded in both August or October 2015. The info within the tables above are as much as October 2018, so one would assume that there was loads of time to right any errors i.e. to incorporate the 2 deaths in August and October 2015.
Excessive incidence of ‘non-malicious deaths’ (these which Letby has not been charged with)
Letby is accused of homicide in relation to 7 of the deaths in 2015 and 2016, however there have been 11 for which she has not been implicated (Chart 1) presumably as a result of she might not have been accountable for them (in reality, the defence, in its opening, stated that she couldn’t have been accountable for a number of the 7 deaths that she has been linked with).
If we assume that ‘non-malicious’ deaths are distributed in accordance with the Poisson distribution (deaths are unbiased of one another and happen at a fee of two.7 per 12 months, the typical of 2013, 2014 and 2017), then the percentages of there being 11 deaths (those Letby has not been accused of) over a two 12 months interval purely by probability is 1 in 83. In different phrases, the prosecution is asking the jury to consider that there’s each a serial killer at work in addition to another issue (e.g. defective gear, understaffed unit, incompetence amongst medical employees) inflicting the deaths. And that these two components each began and stopped at precisely the identical time. Fairly a coincidence!
By the way in which, for many who is likely to be tempted to assume the excessive dying fee fell in 2017 (truly it was from mid 2016) as a result of Lucy Letby was “caught”, do not forget that COCH’s neonatal unit was downgraded in June 2016 and so not was allowed to take care of increased danger infants.
Chart 1
Within the case of Beverley Allitt, the nurse discovered responsible in 1993 of murdering 4 infants, making an attempt to homicide three others, and inflicting grievous bodily hurt to an additional six at Grantham and Kesteven Hospital, Lincolnshire, between February and April 1991, roster information (see under) decided (not like in Letby’s case) that she was current at all 25 of the suspicious incidents that had been investigated (Allitt was not charged for all of them).
Determine: Roster information in Beverley Allitt case
Supply: The Beverley Allitt Tapes (Woodcut Media, Sky Crime documentary)
It also needs to be famous that Allitt by no means testified at her trial (in accordance with the Greensboro Information and Document, Allitt was not “in court docket for 9 weeks of her 13-week trial due to [an] consuming dysfunction and didn’t testify. Colleagues and psychiatrists had been unable to recommend a motive, and she or he has made no public statements” (https://greensboro.com/english-nurse-convicted-in-death-of-infant-patients/article_bec86764-b5ed-5bf1-8d5d-719e01ff22db.html). Letby then again selected to testify and spent 9 days on the stand being cross examined (you possibly can learn all of the experiences in The Chester Customary and choose for your self how she did). Moreover, throughout the hours of police questioning, Letby didn’t as soon as invoke her proper to silence (once more, you possibly can learn lots of the numerous exchanges cited at trial in The Chester Customary). This, too, is not like Allitt, who after a sure level of police questioning refused to say something additional.
Then there may be the case of nurse Colin Norris who was convicted in 2008 of murdering 4 aged sufferers and making an attempt to homicide two others in 2002 (his case was lately referred to the Courtroom of Appeals following a scientific discovering that hypoglycaemia can have a pure trigger and within the aged usually does – in accordance with the prosecution the hypoglycaemia in Norris’ ‘victims’ was attributable to him having injected them with insulin). Norris was initially charged with 5 murders, however earlier than trial roster information decided that for considered one of them he was not current so couldn’t have been accountable. The police then began on the lookout for second assassin, proper? Er, no – they only determined {that a} dying that they had been beforehand sure was a homicide was not in reality a homicide, and lowered the depend to 4.
Excessive incidence of a number of pregnancies in relation to homicide/tried homicide prices
“The obstetricians had been assured of their potential to handle excessive danger pregnancies together with twins and triplets to later levels of gestation, and the place cots and acceptable secure staffing can be found it’s preferable for households to have the ability to keep domestically following supply. The obstetrics group had expressed concern about 4 of the deaths notably, which had been mentioned on the perinatal M&M assembly and located to don’t have any antenatal indicators of concern. The assessment group was nonetheless involved at whether or not there have been enough employees for the LNU to take care of triplets, for instance, albeit publish 34 weeks.” (Clause 4.4.14, RCPCH Report)
Chart 2 under reveals that the share of a number of pregnancies in relation to the homicide/tried homicide prices was manner increased than within the common inhabitants. For instance, within the common inhabitants, 1.2% of pregnancies are a number of pregnancies. Within the case of the pregnancies at COCH the place there was a homicide cost, 50% had been a number of pregnancies (3 of 6). In different phrases, it might be that the deaths and collapses mirrored the excessive danger nature of a number of pregnancies relatively than the presence of a assassin.
Chart 2
Supply: https://www.itv.com/information/granada/2022-10-14/who-are-the-children-alleged-to-have-been-murdered-by-lucy-letby, https://www.raisingmultiples.org/faqs/faq-what-are-the-odds-of-having-a-multiple-birth/
Larger acuity/decrease admission birthweight than common
“Additional in-depth evaluation by the neonatal lead in July 2016 examined exercise and acuity from June 2015. This included admissions per 30 days, time between deaths, complete care days per 30 days, IT care days per 30 days, birthweight and prematurity. This was not a scientific assessment however concluded that there was increased exercise and decrease admission birthweight than common throughout the interval akin to the rise in mortality. This was not nonetheless thought-about to have been important sufficient to clarify the rise in mortality.” (Clause 3.8, RCPCH Report)
I might have an interest to know if the time period “important” was utilized in its strictly statistical sense (i.e. statistical significance). I presume not, as a result of the conclusion seems to be that of the ‘neonatal lead’, not a statistician. Additionally, it seems that the upper exercise/decrease admission birthweight was not thought-about sufficiently important as a result of it couldn’t solely clarify the rise in mortality. Why might it not have been deemed to have been a contributing issue, one amongst others? Then, what about nonlinearity? Presumably there’s a level at which a small proportion enhance in exercise/lower in birthweight results in a big enhance in mortality. To what extent was this thought-about by the neonatal lead?
Issues with UVCs/new UVC steering (UVC = umbilical venous catheter)
“Following reflection each individually and in discussions the consultants famous that a number of of the infants had collapsed unexpectedly and had been surprisingly unresponsive to resuscitation, regardless of the employees following normal protocols in every case. One surviving toddler was talked about as having wanted resuscitation for comparable collapses over three nights however subsequently recovered, though the assessment group didn’t see particulars of ‘close to misses’ resembling this. The consultants didn’t initially contemplate that there have been any hyperlinks between the episodes of collapse within the infants that died however subsequently they started to notice similarities. For instance some of the infants displayed a sudden mottling showing after a couple of minutes of resuscitation, often beginning on the limbs, and on at the least one event on the central stomach and chest. The consultants had thought-about plenty of attainable causes for this look however there remained no particular clarification.” (Clause 3.11, RCPCH Report)
If employees “adopted normal protocols”, why was there a necessity for brand new UVC steering, per clause 3.7? Certainly, there have already been a number of mentions throughout the trial of issues with UVCs in relation to plenty of the infants, as under. To what extent did the consultants contemplate that the collapses might have associated to the UVC points? Since it could have been the consultants who inserted the UVCs, would possibly they’ve most popular to have honed in on Lucy Letby relatively than incorrect insertion of the UVCs?
Extracts from Chester Customary experiences mentioning points with UVCs:
Nurse Melanie Taylor, who was the designated nurse for Baby A on the shift earlier than he died, gave proof in court docket to say she had had “no issues” with him and he was “steady”, however points with a cannula and a UVC meant he was not receiving fluids for a few hours that afternoon. https://www.chesterstandard.co.uk/information/23062657.death-baby-lucy-letby-case-came-completely-blue-witness-says/
A chart reveals any ‘main occasions’ that occurred for Baby A. One was UVC strains at 1pm.
Makes an attempt to suit an umbilical vein catheter (UVC) twice failed
An addendum by Miss Taylor simply after 7pm recorded the UVC was within the incorrect place, and was reinserted, however was nonetheless within the incorrect place.
The UVC was within the ‘incorrect place’ twice – it had been taken out and re-inserted, however was nonetheless within the incorrect place. An alternative choice was sought.
Dr Beech stated the UVC had come out of Baby C throughout a earlier shift
The trainee physician was known as to insert a UVC (a catheter) into Baby A on the afternoon of June 8. Following an X-ray, the catheter was “not ideally positioned”.
The radiology report stated, from the x-ray, the ET tube was ‘in passable place’ following the reintubation, together with the NG tube, whereas a UVC line required additional adjustment.
The UVC was eliminated because it was ‘solely in a position to advance to 5cm’. Dr Rylance says often “you might be anticipated to advance it a lot additional.
An extra word was made to say the UVC ‘continued to ooze’.
A second x-ray picture of ‘successfully the entire physique’ is proven the court docket at June 21, 1.32pm. Professor Arthurs notes two options – the ‘apparent one’ being the UVC going up in the direction of the center, which has been pushed in too far.
UVC nonetheless in situ, however in incorrect place
Small variety of deaths in 2016
In line with the 2016 MBRRACE-UK (Moms and Infants: Decreasing Danger By way of Audits and Confidential Enquiries) Perinatal Mortality Surveillance Report, the variety of neonatal deaths at COCH in 2016 was low (“entry suppressed due to small variety of deaths”), per the under screenshots. And but in accordance with the hospital information introduced above, deaths in 2016 had been excessive. The discrepancy is puzzling and in view of every part ought to be investigated.
Source: MBRRACE-UK Perinatal Mortality Surveillance 2015 and 2016 Experiences
Dr Dewi Evans
Dr Dewi Evans was one of many medical specialists known as by the prosecution.
Requested on the trial on 14 October 2022 by prosecution barrister Mr Myers if he was being ‘an knowledgeable’ in being ‘an knowledgeable witness’, Dr Evans replied: “I feel that is far too flash for me. My function is to help the court docket on some extraordinarily difficult points. I name myself an unbiased medical witness, not an knowledgeable.”
And but on Dr Evan’s LinkedIn profile (under) he states that he supplies “knowledgeable medical recommendation”.
Beneath is an excerpt from The Chester Customary’s report of the trial on Thursday, ninth February, 2023.
A REPORT from knowledgeable witness Dr Dewi Evans in an unrelated civil case was described as “nugatory” by a senior choose, jurors within the trial of Lucy Letby have heard. Retired advisor paediatrician Dr Evans has been known as by the prosecution to provide his opinions as to why plenty of infants suffered collapses on the Countess of Chester’s neo-natal unit. On Thursday, Manchester Crown Courtroom was instructed Dr Evans was criticised over his involvement in an software for permission to enchantment towards a care order involving two youngsters – in a case unconnected to Letby. Dr Evans supported the mother and father’ want to have elevated entry to the kids who had been being cared for by their grandparents, the court docket heard. Refusing permission final December, Courtroom of Attraction choose Lord Justice Jackson stated Dr Evans’ report was “nugatory” and “makes no effort to supply a balanced opinion”. He went on: “He both is aware of what his skilled colleagues have concluded and disregards it or he has not taken steps to tell himself of their views. Both strategy quantities to a breach of correct skilled conduct. No try has been made to interact with the complete vary of medical data or the highly effective contradictory indicators. As a substitute the report has the hallmarks of an train in ‘understanding a proof’ that exculpates the candidates. It ends with tendentious and partisan expressions of opinion which are outdoors Dr Evans’ skilled competence and don’t have any place in a good knowledgeable report. For all these causes, no court docket would have accepted a report of this high quality even when it had been produced on the time of the trial.”
Beneath are some fascinating excerpts from the RCPCH report that was revealed and given to the media in February 2017
“Since June 2015 the paedriatric consultants have grow to be involved a couple of increased than traditional variety of neonatal deaths on the unit, a number of of them being apparently ‘unexplained’ and ‘sudden’. Most of those infants had autopsy examinations, all instances had been reviewed by the mortality and morbidity assembly (M&M), and one had undergone a Root Trigger Evaluation assessment, with some additionally being examined by obstetric secondary assessment. On eighth February 2016 a half day ‘excessive degree’ thematic assessment of ten of the instances occurred with the involvement of the ODN medical lead. A abstract inner assessment of the nursing observations, staffing and junior physician rotas for the 12 hours earlier than the deaths was then carried out. No particular causal correlation was recognized between the varied instances, nonetheless plenty of suggestions (resembling new UVC steering) resulted from the excessive degree assessment.” (RCPCH clause 3.7)
Remark: There have been numerous mentions of points in relation to becoming of UVC in each the RCPCH report and at trial (extra element earlier on this publish).
“The place neonates might require surgical procedure (e.g. swollen stomach) there may be some confusion in regards to the protocol with some clinicians contacting the surgical group at Alder Hey instantly, and others speaking by means of the scenario with the neonatologists in LWH or Arrowe Park first. These pathways had been explored in a surgical assessment in April 2016 which made six suggestions for service suppliers and 5 for the community together with a communication enchancment plan and a single surgical mannequin to scale back confusion and delays.” (RCPCH clause 3.7)
Remark: “confusion in regards to the protocol” amongst clinicians sounds regarding
“Many of the consultants had been on responsibility for at the least one of many deaths. Additional in-depth evaluation by the neonatal lead in July 2016 examined exercise and acuity from June 2015. This included admissions per 30 days, time between deaths, complete care days per 30 days, IT care days per 30 days, birthweight and prematurity. This was not a scientific assessment however concluded that there was increased exercise and decrease admission birthweight than common throughout the interval akin to the rise in mortality. This was not nonetheless thought-about to have been important sufficient to clarify the rise in mortality.” (RCPCH clause 3.7)
Remark: Why had been increased exercise and decrease birthweight not thought-about to have been important sufficient to clarify the rise in mortality? Presumably the relationships (between exercise/birthweight and mortality) aren’t linear i.e. above a sure exercise or under a sure birthweight, mortality will increase non linearly (maybe exponentially). Moreover, witnesses on the trial talked about ‘very excessive quantity’ of admissions.
“Following reflection each individually and in discussions the consultants famous that a number of of the infants had collapsed unexpectedly and had been surprisingly unresponsive to resuscitation, regardless of the employees following normal protocols in every case. One surviving toddler was talked about as having wanted resuscitation for comparable collapses over three nights however subsequently recovered, though the assessment group didn’t see particulars of ‘close to misses’ resembling this. The consultants didn’t initially contemplate that there have been any hyperlinks between the episodes of collapse within the infants that died however subsequently they started to notice similarities. For instance some of the infants displayed a sudden mottling showing after a couple of minutes of resuscitation, often beginning on the limbs, and on at the least one event on the central stomach and chest. The consultants had thought-about plenty of attainable causes for this look however there remained no particular clarification.” (RCPCH clause 3.8)
Remark: If employees adopted normal protocols, why was there a necessity for brand new UVC steering? Additionally, Letby was solely charged in relation to seven of the fourteen deaths from June 2015 to June 2016. What in regards to the different seven, which might nonetheless have constituted an unusually excessive quantity? Why wasn’t Letby charged in these instances?
“In response to this allegation and the excessive acuity and exercise on the unit the Medical Director, Nursing Director and Belief Board selected seventh July to scale back the designation of the service to a Particular Care Unit (SCU) caring for infants from a minimal of 32 weeks gestation pending an exterior assessment by the RCPCH, and the change appeared to have been dealt with sensitively and successfully by administration with good community and public engagement.” (RCPCH clause 3.9)
Remark: It’s removed from clear within the RCPCH report back to what “this allegation” refers but it surely appears to be an allegation that the elevated variety of deaths had been the results of hurt. Nonetheless, the choice to downgrade was additionally because of the excessive acuity and exercise on the unit. In different phrases, it appears to be fairly a coincidence that the elevated variety of deaths was attributable to each hurt having been inflicted and excessive acuity/exercise.
“Two of the cluster of deaths weren’t reported; the present coverage signifies that not all deaths must be submitted as DATIX, if they’re “anticipated deaths”, and in 2015-6 solely 10 of the 13 deaths had been reported as incidents on the neonatal incidents abstract. The definition of ‘anticipated’ was not accessible however presumed to be that utilized in safeguarding/youngster dying panels and it was not clear who’s accountable for DATIX entry. Different areas within the hospital report nicely however the neonatal unit have for a while apparently been much less systematic in reporting.” (RCPCH clause 4.4.5)
Remark: Reporting protocols had been clearly not adopted which is alarming
“There are nonetheless important gaps in each medical and nursing rotas” (RCPCH report Government Abstract)
“The preparations for investigating neonatal deaths have to be strengthened; assessment findings seem like reported at a number of totally different conferences however it’s unclear at which the ensuing actions are monitored. Regardless of sound constructions, there appears to be disconnection between the neonatal management and the Belief’s governance and danger administration processes. Critiques highlighted examples of poor determination making, delays in looking for recommendation, and delayed retrieval of infants to tertiary items.” (RCPCH report Government Abstract)
“The bodily separation of the tertiary centres and lack of tight protocols for switch to them stays a danger as is the commissioner indecision round integration of the three community transport providers, leaving an under-resourced, single medical transport group in Cheshire and Merseyside.” (RCPCH report Government Abstract)
“The service…is non-compliant on nurse and medical staffing ranges, setting and lodging for fogeys, help from the neighborhood neonatal group and postnatal follow-up.” (RCPCH report clause 4.1)
“The paediatrics group has self-assessed towards the 2015 ‘Dealing with the Future’ requirements for acure paediatric care, and said complaince with all requirements besides the primary – advisor presence at occasions of peak exercise. There was a ‘scorching week’ system since 2008-9 however a single advisor is insufficent to soundly cowl each the paediatric and neonatal wards.” (RCPCH report clause 4.1.5)
“There’s inadequate cupboard space leading to many items of kit being saved in corridors. Direct visibility from one space to a different is poor, and infants are moved frequently to accommodate acuity – an additional danger within the system.” (RCPCH report clause 4.1.6)
“BAPM requirements recommend that an annual report ought to be ready for every neonatal unit. No such report had been produced for COCH due, presumably, to strain of exercise so this priceless alternative for affect had been misplaced.” (RCPCH report 4.1.7)
“The paediatric service (together with neonates) struggles to fill its Tier 2 (center grade) posts and medical staffing numbers are insufficient for a Tier 2 LNU, though enough for a Stage 1 SCU.” (RCPCH report 4.2)
“Though…on-paper compliant…there are solely two scheduled advisor ward rounds per week on the neonatal unit, but 5 on the paediatric wards. This might not meet coaching necessities or RCPCH and BAPM steering for a LNU.” (RCPCH report 4.2.1)
“The investigation experiences from the toddler deaths confirmed a sample of inadequate senior cowl and a reluctance to hunt recommendation. Given the acuity of the unit (pre seventh July) there ought to have been a better degree of advisor presence on the ward.” (RCPCH report 4.2.2)
“The assessment group was not conscious of any strategic plans to stabilise the Tier 2 rota resembling improvement of ANNPs or appointment of specialty grade docs, regardless of an annual company value of round £125k. In one of many instances the nurses had expressed concern in regards to the functionality of the locum registrar whose company had beforehand been suggested to not provide the physician to the Belief once more. The nurses took steps to make sure the advisor was conscious however it was not clear to the Assessment group that the locum recruitment course of was sufficiently strong for such a scenario to not recur and no studying/motion was documented for this case.” (RCPCH report 4.2.4)
“There are nonetheless 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.
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