It was June 2016, and almost a year had passed since Stephen Brearey, the lead doctor at a neonatal unit in north-west England, first became concerned about a series of disturbing and unexpected deaths on his ward.
Five babies died, and at least six others experienced unusual complications. The neonatal ward at the Countess of Chester Hospital cares for premature and vulnerable babies, but the death toll is above average for the unit. Something is very wrong.
Then, in the early evening of June 23, a baby boy — one of a set of newborn triplets — suddenly fell ill and died. The following night, while the parents were still shaking, one of the triplets died.
The babies are in the care of Lucy Letby, a seemingly conscientious and well-known nurse. Dr. noticed Brearey said he was present at all the other suspicious cases and had brought that fact up multiple times to executives, but felt his concerns were being ignored.
After the second triplet died, he called a hospital executive and asked to remove Ms. Letby in the ward. The executive said there was no clear evidence against the nurse and insisted she was safe to work with, Dr. Brearey in a court.
A week before Ms. Letby, now regarded as the most prolific killer of children in modern British history, was relegated to clerical duties, and it was months before senior hospital managers contacted the police.
He was finally convicted last week of killing those children by injecting air into their bodies, killing five other infants and attempting to kill six others in his care.
The harrowing case not only shocked the nation but raised deep questions about the workplace culture that allowed him to continue working, even after doctors raised alarms.
Since the trial, clinicians who worked with Ms. Letby, who describes a culture of hostility toward whistle-blowers and fear of scandal that they say means their alerts are ignored.
The hospital delayed contacting the police.
In England, hospitals that are part of the National Health Service, or NHS, are run by individual trusts with their own management teams. The Countess of Chester Hospital Foundation Trust did not contact Cheshire Constabulary, the police force responsible for the area, until early May 2017, a year and a half after doctors first started reporting their suspicion
During the trial, the court heard that several pediatricians who worked with Ms. Letby, 33, including Dr. Brearey, repeatedly alerted hospital executives to their concerns about the nurse.
Dr. John Gibbs, who worked in the department, told Channel 4 news that there was “resistance on the part of senior management to involve the police, but I don’t know why.” He added, “We pediatricians are certainly concerned that someone – and suspicions fall on Lucy Letby – could harm and possibly kill patients on the unit.”
After leaving Ms. Letby in the unit, he started a grievance case against the hospital, saying he was victimized. In January 2017, some of the doctors apologized to the nurse and asked to attend mediation sessions, including Dr. Brearey and Dr. Ravi Jayaram, a pediatrician at the hospital for nearly two decades.
Dr. Jayaram spoke about Ms. Letby in October 2015 and recently told ITV he believes “the babies could have been saved” if the situation had been reported to the police earlier.
“There are things that need to come out about why it took months from concerns being raised to top brass before any action was taken to protect babies,” said Dr. Jayaram in a statement on Facebook on Friday, “and why since then it has taken almost a year for highly paid senior managers to allow the police to get involved.” He declined an interview request from The New York Times.
The case highlights a troubled culture in the health service, experts say.
Medical professionals say the fact that the trust failed to involve the police sooner underlines a wider failure in the NHS. Rob Behrens, an ombudsman who investigates complaints about government departments and health services in England, said the trial showed how, for too long, no one had listened despite repeated alarms.
Mr. is clear. Behrens that the type of intentional killing seen in the case of Ms. Letby is very rare in the health service. But he said ignoring senior managers’ warnings was “depressingly familiar.”
“I see it over and over again in the cases I investigate,” he said, noting that several independent reports in recent years point to a defensive culture and hostility toward those who disclose safety issues.
said Dr. Claudia Paoloni, an executive member of the hospital doctors’ union in Britain, whose case followed a long period in which whistle-blower clinicians were ignored or victimized.
“Every trust should review their existing systems to ensure they are robust and effective,” he said.
said Dr. Jayaram in his statement on Facebook that there is a long history of whistle-blowers in the NHS, “not only being ignored but then presented as the problem, sometimes to the point of their careers being destroyed.”
“What happened here is history repeating itself,” he wrote, “but the patient safety issue that has been ignored is far greater than anything the NHS has tried to cover up before.”
The case has prompted calls for change.
Tamlin Bolton, a lawyer at Switalskis Solicitors, is representing the families of the seven babies victimized by Ms. Letby in civil claims against the Countess of Chester’s trust.
“We really need to look at what is known and what the trust knows in that timeline, to know what they can do and what they should do with what’s presented,” Ms. Bolton.
Immediately after the Letby verdict, the British government ordered a free inquiry “to ensure that important lessons are learned and to provide answers to the parents and families affected.”
But many experts, and representatives of the victims’ families, say this kind of inquiry does not go far enough.
Mr. Behrens, the ombudsman, sent a letter to the health secretary on Wednesday calling on the government to set up a statutory inquiry, which would force those involved to provide evidence, instead of the weaker independent inquiry, which would allow to people to opt out. He also asked for better protection for whistleblowers.
“This is a critical, important moment in the history of our health service,” Mr. Behrens said. “And we need to understand why patient safety is not considered as important as the trust’s reputation.”