From a correspondent

 I first became interested in the Lucy Letby (LL) case when my wife referred me to a 10 hour podcast entitled: “The Case of LL; The Facts – Crime Scene 2 Court Room”, https://www.youtube.com/watch?v=_OA0ukO7D7c. Since, I have searched for further background to this case. Richard Gill’s website raises issues around imbalance between the prosecution and the defence, or lack of it! Also, there was toxic atmosphere at the Countess of Chester (CC) neonatal unit and LL reported problems. I worked for over 25 years anaesthetizing children down to 500g, in addition to adult anaesthesia, as well as expert witness experience. I also spent 6 months attached to a Neonatal Unit. The question of whether LL committed the alleged crimes is a difficult one to answer as (a) no one actually witnessed her doing the alleged crimes, (b) there is no obvious motive, (c) the actions would be very hard to achieve and (iv) there are other alternative explanations that were not explored by the court case, or at least the 10 hour transcript.

The Countess of Chester baby unit: The main purpose of the unit was a nursey to look after and feed babies too small and fragile to leave hospital, born at the CC. There was a small 4 bedded-neonatal unit in addition to the 4 nursery rooms. LL probably wanted to gain neonatal experience hence her involvement with the 17 cited cases.

Neonates and vulnerability: Small preterm babies easily deteriorate and die. Their organs are still developing and without the advent of neonatal units in the 1980s most would die. It is only today that a baby born prematurely before 28 to 32 weeks has a good chance of survival.

Staffing levels, staff experience and standard of care: LL was only 25 years old at the time and had only been a neonatal nurse for a few years. That is not very long and she lacked experience! She still needed further training in Liverpool to advance her career. Yet, she seemed to be one of the most senior neonatal nurses (band 5) on the unit and nowhere in the transcript do we find an older, more senior or experienced colleague other than a charge nurse who managed the duties and was not hands on. Similarly, it appears that medical cover was by paediatricians who also covered the wards and there was no doctor solely on duty for the unit. Therefore, when compared to other bigger units (i.e. Alder-Hey) the level of care was limited, so it would not be surprising if a baby deteriorates, and that happens with “prems”, outcomes are not as good. So, the evidence suggests that the CC was not up to standard, and it was an overflow unit for Alder-Hey. The CC neonatal unit has since been closed down. So were the cited incidents and deaths really due to LL or a result of a poorly supported / under-funded unit looking after sick neonates that should have been elsewhere?

The prosecution case focused on a number of methods of harming babies allegedly used by LL: (i) Distending the stomach by giving too much feed or (ii) injecting air into the stomach, (iii) injecting air into the circulation causing sudden collapse, (iv) traumatising the airway and causing bleeding, (v) dislodged tracheal and chest tubes, and (vi) adding insulin to the intravenous feed. The discussion of the pathophysiology of these mechanisms was disjointed and difficult to follow. However, the connection of LL to the sudden deteriorations and deaths in 7 seemed very compelling. However, I have to take issue with a number of the prosecution’s assertions.

(i) Over-distending the stomach with feed to an extent to cause collapse and projectile vomiting. I don’t have any experience of tube feeding prems, but projectile vomiting can be a reaction to bad / infected milk? Was LL in hurry to feed the baby? I find it hard to believe this was an attempt at murder.

(ii) Most obvious was the air in the stomach and intestines at post mortem. LL must have injected air via the gastric feeding tube, or how else did it get there? Well anyone who works in theatre or resuscitation knows during mask ventilation, which all these babies had (i.e. Neopuff), that it is very easy to blow up the stomach and intestines with air / anaesthetic gases, especially if one’s technique is not perfect. I regularly had to pass a suction catheter to empty the stomach of gas at the start of surgery to deflate the stomach and improve ventilation. I even did a study on the carbon dioxide levels that often reached the level of expired gas. However, the role of the Neopuff as a potential cause was never mentioned. So what is more likely, LL injected the air or the air got there through resuscitative efforts by stressed staff.

(iii) Some of the babies suddenly collapsed and developed a strange rash on the abdomen. Some recovered rapidly. This was said to be due to LL injecting air into the circulation. Air was found to be in the blood vessels at post mortem in some deaths. The premature baby can revert to a foetal circulation (by passing the lungs) when they become unstable and this can take time to treat (revert back). Sometimes “persistent foetal circulation” manifests itself during anaesthesia until the ductus closes fully. Point not mentioned in the case but could explain the above. Also, chest compression would cause significant sucking in of air to the heart if intravenous access lines were left open to air during the resuscitation after injecting a drug (adrenaline). LL sent a Datex about a line being left uncapped by one of the doctors. So there are other explanations and mechanisms by which air could have entered the circulation.

(iv) One of the cases had trauma to oral airway and significant blood loss, I think this was one of the twins with Haemophilia, a blood clotting disorder. LL was accused of traumatising the airway. I cannot imagine how. The likely explanation would be repeated intubation attempts, not an attempt to murder the baby by LL. I recall up to seven attempts as the neonate was difficult to intubate!

(v) LL was also accused of dislodging an endotracheal tube and a chest drain which lead to deterioration in two patients. Preterm babies are very small, endotracheal tubes can easily move and become dislodged however carefully one secures them, particularly if the neck is flexed or extended! Similarly, with chest drains, the baby had bilateral drain presumably as a result of premature lungs, and one drain became dislodged / was not working and a third drain was needed. These things happen so just because LL was present does not automatically mean it was her fault. Then there was the incident with deliberate liver injury, which equally could have occurred during chest compressions by someone else?

(vi) The addition of insulin to intravenous feeds has already been mentioned by Gill from a biochemistry and reliability of blood test perspective. I don’t fully understand this one. One baby was receiving regular intravenous nutrition made up in sealed bags from pharmacy. The baby had unexplained hypoglycaemia. For three bags it persisted and when LL was not on duty the hypoglycaemia resolved. Blood were analysed insulin and C peptide. Hypoglycaemia is common in preterm babies because their mechanisms to maintain blood glucose levels are immature (i.e. glycogen stores in the liver). The child may have had an infection as Gill says there was virus circulating. That being said it difficult to image how LL managed to injected the correct and same amount of insulin into a sealed bag on three separate occasions. There is a rigid nursing protocol involving two nurses when a new bag is put up to maintain sterility. Then there was a further insulin contaminated Dextrose infusion in a second baby. BTW, LL was not the only nurse present for both these cases.

Hence, I find it very difficult to accept the verdict that Lucy Letby was responsible for all 7 deaths and a further 6 attempts at murder. I think that her case needs to be reviewed by someone with a better understanding of neonatal medicine and how a premature baby unit is run.

Signed Lester; 20.10.2023