The following text is taken from Science on Trial, https://www.scienceontrial.com/, I will later link to the precise location on that website, and find out if the author may be named.
After having read through multiple articles detailing the timeline of the circumstances behind of the allegations, I thought I’d provide a brief but detailed history of the sequence of events resulting in Miss Letby being arrested and charged. I’m sure many of you know this timeline already, hopefully there are more details here you will find interesting. For those who don’t know the chronology, I hope the below is useful. That this was a fairly open conspiracy between senior consultants at the hospital, primarily Dr Stephen Brearey (he is in fact the architect) and Dr Ravi Jayaram, and later detectives at Cheshire Police assigned to the case titled ‘Operation Hummingbird’ is difficult to dispute. They’ve quite openly admitted it by clumsily showering praise on themselves following the trial in a bizarre attempt to characterise themselves as heroes. Although the record is fragmented and the sources are scattered, a reconstruction is possible nonetheless.
-On June 8 2015 Child A, a premature newborn twin, suddenly collapses on the neonatal unit. Dr Ravi Jayaram, who responds to the emergency alert, later testified that he noticed “pink patches, mainly on the torso, which seemed to appear and disappear and flit around. I had never seen anything like it before but my focus at the time was on ABC, airway, breathing, circulation.” He added: “I could not explain the sequence of events, why they had happened. I couldn’t explain why it had happened in the first place and couldn’t explain why the physiological responses to timely and appropriate interventions did not happen as they should have happened.” Dr Jayaram does not mention the skin discolouration in the clinical notes he made three hours after Child A died. He testified “I didn’t appreciate the clinical significance of this whatsoever”. When asked why he also failed to mention it to the coroner presiding over the inquest of Child A, Dr Jayaram replied: “My concluding remarks when I gave evidence is that I couldn’t explain how this had happened, It was not my job to say ‘it may have been this’ because at that time I had no evidence”.
-Around midnight on 9 June 2015, Child B’s blood/oxygen levels drop. She is blue, not breathing and limp.
-In the early hours of 14 June 2015 Child C suddenly collapses. He is pronounced dead at 5:50am.
-On 21/22 June 2015, Child D collapses three times, the last one being fatal. Those present notice discolouration on the babie’s skin.
-Towards the end of June 2015, after Child D’s death, Dr Stephen Brearey notices that Lucy Letby is on shift for each instance of four collapses, three of them fatal, in the last two weeks. She is the only nurse present in each case. Dr Brearey shares this informal review with Dr Ravi Jayaram. He tells Dr Jayaram that nothing linked the deaths “other than one nurse”. The deaths are reported by consultants to hospital’s trust committee for serious incidents. The hospital classifies them as “medication errors” and not a “serious incident involving an unexpected death”.
-By June 2015, Dr Brearey, Dr Jayaram and “other colleagues” all identify Miss Letby as a potential link.
-On 29 June 2016 the entire consultant body at the hospital hold a meeting concerning the collapses. Air embolism is one of the topics discussed. That evening Dr Jayaram conducts a literature search and comes across the 1989 medical paper titled “Pulmonary Vascular Air Embolism In The Newborn”. Dr Jayaram will later testify to the court that the paper describes a series of accidental events of air embolism. The context within which the research paper studies air embolism is as an inadvertent complication of mechanical ventilation. Dr Jayaram emails links to the medical paper to colleagues the next day.
-On 2 July 2015, Dr Stephen Brearey, Eirian Powell, a nurse and ward manager responsible for the nursing staff on the neonatal unit, and Allison Kelly, director of nursing at the hospital hold a meeting. Lucy’s presence when the three deaths occurred is discussed.
-By October 2015, seven infants have died in unusual circumstances. Dr Brearey openly suspects Miss Letby is harming children. Miss Letby will go on to be convicted for murdering five of these infants. The remaining two, despite being investigated by the police, were never bought to trial.
-On 23 October 2015 Eirian Powell emailed the findings of her own review of these collapses to Stephen Brearey. She states “I have devised a document to reflect the information clearly and it is unfortunate she [Miss Letby] is on [shift] – however each cause of death was different, some were poorly prior to their arrival on the unit and the other were ?NEC or gastric bleeding/congenital abnormalities. I have attached the document for your perusal”.
-In February 2016 Dr Brearey orders a half-day thematic review into the deaths and collapses with the help of Consultant Neonatologist at Liverpool Women’s NHS Foundation Trust Dr Nimish Subhedar. It finds several common links in nine unusual deaths since June 2015. Four of these were never brought to trial.
-On February 15 2016, The report is sent to Ian Harvey, the hospital’s medical director and second in charge, and Allison Kelly. It includes a table of the nine deaths identified in the review, showing Miss Letby is on shift for each one. Dr Brearey requests an “urgent meeting”. Management determine Miss Letby’s presence is a coincidence.
-On March 17 2016, Eirian Powell & Allison Kelly discuss via email how Miss Letby was a commonality in the deaths.
-On April 7 2016, Eirian Powell moves Miss Letby to day shifts to support her wellbeing because she had been present for so many of the collapses.
-On April 9 2016, Child M suffers a dramatic drop in heart rate and breathing. This occurred during a day shift and is used to suggest that deaths and collapses “follow” Miss Letby.
-In May 2016, Dr Brearey emails Allison Kelly, flagging Miss Letby’s presence at the deaths and asking for a meeting. Allison Kelly fowards the email to Ian Harvey expressing alarm that a doctor was implicating a nurse. She tells Ian Harvey that there was no evidence but that a wider review might be needed. Allison Kelly asks senior nurse managers to examine any staffing trend linked to the deaths, adding that it was ”potentially very serious“.
-On 11 May 2016 Dr Brearey and other doctors meet Kelly and Harvey to discuss their concerns about Miss Letby. The senior managers produce a two-page “assurance” document detailing why Miss Letby is not believed to be the cause of the unusual deaths. It suggested other NHS services may be to blame for the spike in deaths and that: “There is no evidence whatsoever against LL other than coincidence”. They agree to review all the deaths and keep Miss Letby on day shifts for three months. Dr Brearey feels his concerns have been dismissed.
-On 16 May 2016, a senior doctor tells Eirian Powell during a meeting: “You are harbouring a murderer”.
-On 23 June 2016 newborn triplet, Child O, dies after a number of collapses.
-On 24 June 2016 Child P, the brother of Child O, suffers an ‘acute deterioration’. He suffers a number of collapses and is finally pronounced dead at 4pm. The coroner later recorded the death as ‘prematurity’. The prosecution later claimed Miss Letby injected air into his stomach. Stephen Brearey calls hospital nursing director Karen Rees to express his concerns. He no longer wants Miss Letby working on the unit. Rees insists there is no evidence against Miss Letby and says she will take responsibility for allowing her to continue to work.
-In late June 2016 emails are exchanged between nurses, doctors and hospital executives. One of the doctors recommends calling the police. Ian Harvey replies to the chain saying concerns were being “discussed and actions taken”.
Executive directors at the hospital meet and debate calling the police for the first time. They consider the impact of an investigation and arrest, and subsequent reputational issues and impact on the trust. They acknowledge the evidence is circumstantial and express their concerns about the unit’s leadership. They fear the doctors are carrying out a witch-hunt. The trust do not contact the police.
The neonatal unit is downgraded to level 1 so that the sickest and most premature children are sent to neighbouring hospitals. Ian Harvey and Tony Chambers, the hospital’s chief executive, contacts the Royal College of Paediatrics and Child Health and asks them to review the neonatal unit’s service level. The hospital’s executives meet the doctors and tell them they considered contacting the police but decided to handle it in a different way.
-By July 2016 mortality data shows there had been 14 neonatal deaths in just over a year. An internal review by the nursing director notes that higher acuity levels, higher activity and short staffing levels may have all contributed. It does not mention any concerns around any individual. Miss Letby is called to a meeting with a senior nurse and a HR Manager. She is told for the first time of her association with the infant deaths. She is visibly upset and distressed. The decision has been to place her under supervision, alongside other staff.
-In mid-July 2016 Miss Letby is redeployed to the hospitals risk and patient safety office. Staff shortages on the neonatal unit meant supervision of her was not possible after all.
-In early September 2016, the RCPCH arrive and begin their investigation. Miss Letby is one of the first to be interviewed.
-On 7 September 2016 Miss Letby submits a formal grievance against the trust for victimisation and discrimination at being removed removed from the ward. This is after learning through her Royal College of Nursing representative of the concerns by doctors on the unit.
–In October 2016 the RCPCH report back to Harvey and Chambers. They find that what had happened ”appears unusual and needs further inquiry to try to explain the cluster of deaths“. A draft version of the report is drawn up. It raises general concerns around short staffing and clininal practices. It notes an increased volume of cases with increased acuity levels, but states this was not significant enough to explain the high mortality rate. It also says there “no obvious factors which linked the deaths and that circumstances in the unit were not materially different from those which might be found in many other neonatal units”. However it recommends detailed case reviews are needed for each of the deaths, including examination of obstetric, pathology, nursing and post-mortem indicators. It also includes a confidential section linking the deaths with Miss Letby and the subjective concerns of Dr Stephen Brearey, the neonatal lead. This section is redacted from the version circulated to the board, the doctors and the bereaved parents.*
Ian Harvey contacts Dr Jane Hawdon, a neonatalogist, asking her to carry out a forensic review of each death. Hawdon produces a five page review but tells Harvey she did not have the time to conduct the thorough investigation the royal college had recommended. Nonetheless it cited four cases which could not be explained but would “potentially benefit from local forensic review as to circumstances, personnel etc.”
The executive managers meet again and agree that not calling the police the was the right decision as the doctors’ evidence was “unconvincing”.
-In November 2016 two and a half months have passed since Miss Letby’s grievance. During the investigation, Doctors who raised concerns about her causing harm to infants, including Brearey and Jayaram, were interviewed, with their union reps present, by an investigator. The investigation finds no evidence to justify calling in the police. Instead it finds the doctors are at fault for suspecting her of murder. ”This behaviour has resulted in you, a junior colleague and fellow professional, feeling isolated and vulnerable, putting your reputation in question,“ the grievance inquiry told Letby. ”This is unacceptable and could be viewed as victimisation“.
-On 12 November 2016 HR prepare Miss Letby’s return to the neonatal unit.
-On 22 December 2016 Tony Chambers issues Miss Letby with a full apology on behalf of the hospital trust, and assures her family the doctors who had victimised her would be dealt with.
-In January 2017 the hospital board hold a meeting. Harvey states the RCPCH review found the incidents were down to issues of “leadership, escalation and timely intervention” and that it “does not highlight any single individual”.
In a separate meeting, Harvey and Chambers tell seven clinicians, including Brearey and Jayaram, that “things have been said and done that were below the values and standards of the trust.” Mediation between Miss Letby and both Brearey and Jayaram was demanded. They were told it would protect them from a referral to the General Medical Council (GMC), the doctors’ watchdog. The British Medical Association Rep advised them to write a letter of apology to Miss Letby.
-In late January the doctors write to Harvey. They ask “what is the reason for the unexpected and unexplained deaths? What should we as paediatricians do now?”
-On 1 March 2017 the paediatricians write a letter of apology to Miss Letby.
-In March 2017 the consultants seek external advice from the regional neonatal lead who agrees that several cases require further investigation. They meet again with Harvey and Chambers to ask police to investigate. At this point it was agreed. The high deaths and suspicions were raised with police through the local child death and overview panel.
-On 27 April 2017 Detective Superintendent Paul Hughes meets Dr Brearey and Dr Jayaram at the Countess of Chester Hospital. The meeting proved decisive. Dr Jayaram said “the police, after listening to us for 10 minutes, realised this is something they had to be involved in”. Whether the name Lucy Letby was mentioned at this meeting or a little later is irrelevant. The next day Operation Hummingbird was launched, and more than a year later on 3 July 2018 Miss Letby was arrested.
The most disturbing facts I came across while researching this piece was that two fundamentally vital pieces of evidence cited in the trial by the prosecution, had long been prepared by the doctors before the name Dewi Evans became remotely connected.
(i) The table that showed Miss Letby on shift for all the collapses and deaths had already been built by Dr Stephen Brearey in February 2016.
(ii) The air embolus theory had already been determined as her modus operandi as early as June 2015. Dr Jayaram had been sitting on the 1989 paper since June 2015.
Furthermore whilst not discussed above, Dr Stephen Brearey just so happens to be the very doctor who finally finds the so-called ‘smoking gun’. On 13 February 2018 discovers the blood sample for Child F which apparently proves deliberate harm in the form of insulin poisoning. Incidentally, Vincent Marks is a Doctor of Medicine and Clinical Scientist who has conducted highly relevant research into the forensic aspects of hypoglycaemia. His works include: ‘Insulin Murders’, ‘Hypoglycemia: Accidents, Violence and Murder’. He claims that a fatal dose of insulin for an adult human being is around 1,000 units. Child F’s level was 4,657 units.
*Redacted passages: “The neonatal lead [Stephen Brearey], in an effort to be thorough and explore all possibilities had identified that one nurse had been rostered on shift for all the deaths although the nurse had not always been assigned to care for that specific infant. Subsequently, the paediatric lead and all the consultant paediatricians had become convinced by the link. Although this was a subjective view with no other evidence or reports of clinical concerns about the nurse beyond this simple correlation an allegation was made to the Medical Director and Director of Nursing.
“On arriving for the visit the RCPCH Review team was told that the nurse had been moved to an alternative position around ten weeks previously without explanation nor any formal investigative process having been established. The Review team was told that the individual was an enthusiastic, capable and committed nurse who had worked on the unit for four years. She herself explained to the Review team that she was passionate about her career and keen to progress. She regularly volunteered to work extra shifts or change her shifts when asked to do so and was happy to work with her friends on the unit. The Directors understood there was nothing about her background that was suspicious; her nursing colleagues on the unit were reported to think highly of her and how she responded to emergencies and other difficult situations, especially when the transport team were involved. There were apparently no issues of competency or training, she was very professional and asked relevant questions, demonstrating an enthusiasm to lead along with a high level of professionalism.
Idiot.
Thank you, Jane, for your very wise remark. I did not bin it, because it is important for everyone to see the high intellectual level of all those who think Lucy should rot in hell. To call them morons, or compare them to pitchfork wielding peasants, is insulting to morons and to peasants.
I had understood that the RCPCH review effectively cleared Letby. That chronology suggests otherwise, that it was inconclusive.
The doctors may have put her in the frame, but that does not make her innocent, and they may have focused on her in the belief she’s guilty.
I think it is more subtle. The report says that a *forensic* investigation was needed to find out the cause of the *few* cases for which they could not determine a cause. They don’t say ‘a police investigation’. They are as convinced as they could be, given the possibilities for investigation which they had at their disposal, that the nurses were not to blame.
Forgive me Professor, but what the above piece says about the RCPCH Review is not what you claim. I am now going to reproduce the relevant paragraph in full:
[quote]”In October 2016 the RCPCH report back to Harvey and Chambers. They find that what had happened ”appears unusual and needs further inquiry to try to explain the cluster of deaths“. A draft version of the report is drawn up. It raises general concerns around short staffing and clininal practices. It notes an increased volume of cases with increased acuity levels, but states this was not significant enough to explain the high mortality rate. It also says there “no obvious factors which linked the deaths and that circumstances in the unit were not materially different from those which might be found in many other neonatal units”. However it recommends detailed case reviews are needed for each of the deaths, including examination of obstetric, pathology, nursing and post-mortem indicators. It also includes a confidential section linking the deaths with Miss Letby and the subjective concerns of Dr Stephen Brearey, the neonatal lead. This section is redacted from the version circulated to the board, the doctors and the bereaved parents.”[unquote]
If this account is anything to go by, it appears that the problem here is that the hospital management may have misrepresented to the board what the RCPCH Review actually found. In simple layman’s terms, the Review was inconclusive and didn’t clear Letby or the nurses generally. Nor was it their role or remit to ‘clear’ anybody, it should be added.
I’m afraid the position is not as you represent it at all. I realise they didn’t recommend a referral to the police. That’s very clear from what is written above, but they plainly say that further examination of all deaths is needed.
I’m not a fan of interpreting things to favour one side or another. I have no dog in the hunt. Best just to work on facts and follow where it leads, and if that means she looks guilty, so be it, and if it means there’s doubt as to her guilt, again so be it.
Thanks, that is excellent work. We need to see the confidential section. What does the word “linking” mean? Already in 2015 Dr Brearey explicitly linked one of the two triplets to Miss Letby in the sense that he thought she had maliciously caused the events to happen, and in 2016 the second triplet. Neither then, nor later, was any further link made, till the consultants effectively linked Lucy to numerous collapses which occurred on her shifts by making sure the medical notes of those events all went to the police (with the exception of the two so-called insulin babies, which only came in 2018 when Brearey had gone hunting again for smoking guns and at last thought he had hit the jackpot).
I keep on reading in various places that the gang of four (doctors), after numerous approaches to CoCh management to call in the police and their requests being rejected , they themselves went to the police. This it seems is incorrect. It would have been significant if this was the case – that they went over the heads of bosses – in that their convictions would have appeared to be strong, strong enough to risk disciplinary action from management.
Numerous people have reported that the gang of four (doctors), having had their requests for police involvement rejected by management, went direct to the police themselves. It would appear that this is incorrect. If indeed the gang of four had chosen to ignore their management and gone direct to the police, this would have indicated some conviction as to their suspicions. Convictions I have never believed they had.
What appears right now is that after the RCPCH report came out, management capitulated to the gang of four. Who actually went to the police is not clear, but it seems obvious that the gang of four prepared medical dossiers for the police: this was clearly a job for medical personnel of the hospital. Who decided which dossiers to submit? It seems that this was the gang of four.
But in any case, the RCPCH report recommended a *forensic* investigation of the few cases (death, collapses) for which there was no obvious explanation. It did not recommend police involvement! The RCPCH was bothered by the strange mottling or rash or discolouration of some babies. One does not ask the police to do a forensic investigation. One asks a forensic research institute or company, after locating one which might have the necessary skills and capacity for medical forensic research. Since the UK closed down its own (once world renowned) national Forensic Science Service in a frenzy of privatisation, chaos ensued. Probably the best place to go to would have been the national forensic institutes in Eire or the Netherlands; I don’t know if any UK university has an adequate medical forensic unit which does really difficult contract work.
Essentially the gang of four didn’t go against management’s wishes in going to the police – if it was them, it was with agreement of management. Only a small issue, but the minutiae of this crazy farrago of events become important when one considers the consequences of each and every small action of theirs ending in a young woman serving a whole life sentence, and being portrayed as evil personified. Without any special insight, I have the belief that any number of the gang of four seriously doubt Lucy’s guilt. I say that on the basis that they are, all of them, normal rational human beings without serious mental disorders. Smarter people than me have suggested that individuals can go to incredible lengths to protect their own status, to the point of scapegoating others. But this scapegoating, if it is such, will in the end destroy them.
The air embolism theory is mooted “-On 29 June 2016 [when] the entire consultant body at the hospital …[etc]” If this is indeed 2016 (as it seems to be from other sources) then it should be placed correctly in the timeline.