To move very quickly. Dan roan, bbc news, sydney. This programme continues on bbc one. After a trial lasting 10 months, a jury decided nurse lucy letby deliberately injected seven babies with air, force fed others milk and poisoned some with insulin. Her victims included twins and two boys in a set of identical triplets, who she murdered within 2a hours of each other. Consultants who told Hospital Managers they had concerns about letby were forced to apologise to herfor raising suspicions. Well ask why bosses at the countess of Chester Hospital, where she worked, failed to investigate the deaths for so long. There is only one Serial Killer of babies. The Executive Team were not the people who were responsible for the deaths of those babies, but they had some opportunities to get to the bottom of what was happening. And why does a Health Professional trained to save lives become a Serial Killer . The person who kills within a Healthcare Setting has already developed the desire to kill, and if you want to kill, of course youre going to identify people who are vulnerable, people whose deaths wont be noticed. Also tonight great play. Its toone oh, wow as englands women prepare to make history by playing in the World Cup Final on sunday in sydney, we report on how the lionesses have fuelled the dreams of young girls around the country. Theyre just winning all the time and its just inspiring, because, like, i want to be like them when i grow up. I want to be a football player. England mens arent winning and the womens are good evening. We will never know the names of the seven babies nurse lucy letby murdered. They havent been revealed to protect them and their families. We do know that five of them were baby boys and two were baby girls. And there are six more infants letby tried to kill. They will now be approaching their eighth birthdays. During letby� s long trial, the court heard that her favourite way of murdering them was by injecting them with air. She was, the prosecution said, in effect playing god. Cheshire police have announced today that they will now be reviewing the care of thousands of babies at two hospitals where letby had worked. Tonight well ask why bosses at the countess of Chester Hospital failed to investigate the suspicious deaths of so many babies, despite consultants repeatedly trying to blow the whistle about the numbers dying on letby� s watch. The hospital didnt answer that or any other questions today. The answer may come via an inquiry which has been announced by englands health secretary. Heres kate. Did you have any concerns that there was a did you have any concerns that there was a rise did you have any concerns that there was a rise in did you have any concerns that there was a rise in the Mortality Rate . Yes yes. Seven babies murdered in a Neonatal Unit, a further six the subject of murder attempts. The Verdicts Today Make Lucy Letby the most prolific child killer in modern british history. The nurse had been trusted to care for the largely premature and vulnerable infants at the countess of Chester Hospital. She sought to deceive her colleagues and pass off the harm she caused as nothing more than a worsening of each babys existing vulnerability. She perverted her learning and weaponised her craft to inflict harm, grief, and death. The deaths took place over a year from june 2015 untiljune 2016. During the trial, the Court Heard Babies at the unit experienced sudden and inexplicable collapses. Medical experts for the prosecution suggested they were caused by injections of air into the babies circulation, air being fed in to a nasogastric tube, doses of unprescribed insulin and overfeeding. Lucy letby was cleared of two charges of Attempted Murder. The jury was not able to make a decision on six further charges. The defence argued the deaths were related to wider feelings of care within the hospital. Families have remained anonymous throughout the trial, but one has spoken to the bbc. In august 2015, the mother of baby e entered the Neonatal Unit to visit her child. I entered the Neonatal Unit to visit her child. U, entered the Neonatal Unit to visit her child. ,. , entered the Neonatal Unit to visit her child. U,. ,. , her child. I could immediately hear c inc. It her child. I could immediately hear crying it felt her child. I could immediately hear crying. It felt more her child. I could immediately hear crying. It felt more than her child. I could immediately hear crying. It felt more than crying. Crying. It felt more than crying. It was screaming. It was screaming, and i was like, what is the matter with them . I walked i was like, what is the matter with them . Iwalked into i was like, what is the matter with them . I walked into the room to see if it was my boy. He had blood round his mouth, and she was there, lucy. She said, dont worry, the registrar is coming, and told me to go back to the ward. Baby e would die hours later. The following day, the condition of baby es Twin Brother Baby F suddenly worsen. It was understood later he had been given insulin. Baby f has been left with severe learning difficulties. Lucy letby has been found guilty of baby es murder and the Attempted Murder of baby f. I think she is a hateful human being. She has taken everything from us, absolutely everything, because what she has done has changed the course of our life forever. I she has done has changed the course of our life forever. Of our life forever. I have been asked to of our life forever. I have been asked to read of our life forever. I have been asked to read out of our life forever. I have been asked to read out a of our life forever. I have been asked to read out a statement| of our life forever. I have been i asked to read out a statement on behalf asked to read out a statement on behalf of asked to read out a statement on behalf of all the families in this case behalf of all the families in this case this behalf of all the families in this case. Thisjustice will not behalf of all the families in this case. This justice will not take away case. This justice will not take away from case. This justice will not take away from the extreme hurt, anger and distress we have all had to experience. We are heartbroken, devastated, angry and feel numb. Lucy letby devastated, angry and feel numb. Lucy letby was in court to hear the first guilty murder verdicts, reportedly sobbing at the news. More recently, she has chosen not to appear in court. Letby will be sentenced on monday. Lucy letby isnt the first medical professional to use her training and uniform to deceive and manipulate colleagues and relatives, and to kill patients. We might never know why she did what she did. Heresjoe. She is not the first nhs Serial Killer, and lucy letby is unlikely to be the last. Beverley allitt, Harold Shipman and colin norris were all convicted of murdering their patients. And as with lucy letby, in each case, the authorities were asked, why werent they stopped sooner . Dr shipman targeted those who trusted him, elderly, vulnerable patients, and injected them with morphine. The bodies of nine of his victims were exhumed as part of the police investigation. He was jailed in 2000, and killed himself in prison four years later. She has been found with a quantity, that much, insulin in her. Elderly patients were also the target of colin norris, a young nurse who went rogue. In 2008, he was found guilty of murdering four, and trying to kill a fifth. But the closest comparison to letby is perhaps Beverley Allitt also a nurse in her 20s, also working on a childrens ward, this time in lincolnshire. In 1993, allitt received 13 Life Sentences for the murder and Attempted Murder of infants. And we thought we would try and look at this to see how big the phenomenon was. Criminologist david wilson has studied doctors and nurses who become Serial Killers. The person who kills within a Healthcare Setting has already developed the desire to kill before theyjoin the Healthcare Setting, and if you want to kill, of course you are going to identify people who are vulnerable, people whose deaths wont be noticed, and so, guess what . The people that Serial Killers target, by and large, are older people, or they target very, very young people, specifically in a Neonatal Unit, in this case, where again, small babies with chronic underlying healthcare, where their deaths wont be commented upon, or seen as being suspicious, because tragically, some babies born in that situation will die. Thejudge led Inquiry Following Beverley Allitt� s conviction in 1993 criticised the speed of the hospitals response. Again, there are comparisons with lucy letby. At the countess of Chester Hospital, managers did not properly investigate how 13 babies had died unexpectedly in a single year, even though doctors had raised concerns. Susan gilby took over running the nhs trust soon after lucy letby� s arrest. The paediatricians were discussing, you know, the terrible nights on call that they were having. One of them said, every time this is happening to me, that im being called in for these catastrophic events which were unexpected and unexplained, lucy letby is there, and then Somebody Else said, yes, i have found that. And then someone else had the same response, and they all realised that the common factor for each of them was letby� s presence on the unit. The first three babies died injune 2015. Senior managers agreed to hold an external investigation. That never happened. Four months later, four more babies were dead, and a Staff Analysis linked lucy letby to every one of them. By the following february, ten babies had died, but when doctors ask two senior managers for an urgent meeting, they did not respond for three months. Injune, over two days, two more babies died. Lucy letby was on shift for both. By now, there had been 13 unexplained deaths. In september, the Royal College of paediatrics and child health urged the trust to investigate each death individually. That didnt happen. It was only the following may, after continual pressure from staff, that the trust called the police, almost two years after the first unexpected deaths. When she was arrested injuly 2018, lucy letby was still working at the trust. No disciplinary action had been taken against her. There is only one Serial Killer of babies thats worked in that organisation, and the Executive Team were not the people who were responsible for the deaths of those babies, but they had some opportunities to get to the bottom of what was happening. The reputation of the organisation, and protecting that reputation, was a big factor in how people responded to the concerns raised. The months of inaction is no shock to this former nhs Whistle Blower and former nhs manager. Not surprised at all. Trusts generally delay everything for as long as is possible. Now, whats here is that, like many nhs trusts in which tragedies have occurred, for different reasons, obviously, to this specific case, youll find that the prompts for action come from outside the system, because the system ignores its own people. If you come at the system, if you approach directors and senior managers with good news without evidence, that is welcomed, thats taken on board, and youve just got to look at what was going on, whether its shrewsbury and telford, whether its Nottingham Hospitals maternity units, or whether its, you know, going back to mid staffs, yeah . When good news is put forward, even though its baseless, its welcomed, but when negative news, what i would perceive as factual news, when that is brought forward, even with evidence, it tends to be pushed aside, because it doesnt suit the narrative. One question remains about lucy letby� s murders. Why . Sometimes the healthcare Serial Killer will say that, i was actually being merciful. This person was in a great deal of pain, and i wasjust ending quickly. Other healthcare Serial Killers have often just wanted, because the unit was under such pressure, theyjust tried to get rid of difficult patients. You know, weve cleared another bed. You know, it wasjust a kind of sort of managerial efficiency that they seemed to be expressing. I think on the basis of what emerged at court, we might be able to infer what might have motivated her, and there did seem to be a hero complex. The babies who survived lucy letby� s crimes will now be approaching their eighth birthdays. It has been a distressingly long wait for the doctors and nurses to be believed, and for the families to getjustice. The former Medical Director at the countess of Chester Hospital said in a statement the hospitals former Chief Executive added and you can watch a special bbc panorama programme, lucy letby the nurse who killed on bbc iplayer. Lets speak now to professorjames walker, who was clinical director of Maternity Investigations at the Health Services Investigation Branch between 2018 and this year, and minh alexander, retired Consultant Psychiatrist and nhs whistleblower. Thank you both for being on the programme. James walker first of all. Consultant paediatricians as we have heard raised concerns about lucy letby with the managers, managers repeatedly failed to investigate. That beggars belief, doesnt it when we are talking about the deaths of 13 babies . Yes. Doesnt it when we are talking about the deaths of 13 babies . The deaths of 13 babies . Yes, it does but it the deaths of 13 babies . Yes, it does but it is the deaths of 13 babies . Yes, it does but it is not the deaths of 13 babies . Yes, it does but it is not unusual, the deaths of 13 babies . Yes, it does but it is not unusual, the l does but it is not unusual, the doctors have good evidence from their own site, from what they have seen and feel but they dont have strong evidence that something has gone wrong but what they have asked for is an inquiry, what has already been said a lot the executive dont want an inquiry unless there is good evidence, so there is that gap in the middle. That is why the system should be changed to allow incident like thissing to flagged up and investigated without decisions having to be made by the executive, they cant really investigate themselves, there has to be a system to allow full investigations to be carried out without decisions being made at executive level. [30 carried out without decisions being made at executive level. Carried out without decisions being made at executive level. Do you buy that minh alexander, made at executive level. Do you buy that minh alexander, that made at executive level. Do you buy that minh alexander, that managers unless there is evidence wont investigate . I unless there is evidence wont investigate . Unless there is evidence wont investigate . Unless there is evidence wont investiaate . �. ,. ,. , investigate . I couldnt hear all all ofthat investigate . I couldnt hear all all of that last investigate . I couldnt hear all all of that last reply investigate . I couldnt hear all all of that last reply i investigate . I couldnt hear all all of that last reply i am investigate . I couldnt hear all all of that last reply i am afraid of that last reply i am afraid because of that last reply i am afraid because of. Because of the feedback because of. Because of the feedback because of. Because of the feedback. ,. ,. ,. , feedback. Let me ask you, you were a whistleblower, feedback. Let me ask you, you were a whistleblower, there feedback. Let me ask you, you were a whistleblower, there were feedback. Let me ask you, you were a whistleblower, there were people i feedback. Let me ask you, you were a whistleblower, there were people in| Whistle Blower, there were people in the countess of chester who could be described as Whistle Blowers and they were ignored. Let by wasntry moved from clinical duties until june 2016, a year after babies started dying when she was on shift. Why so slow . What is going on in managers heads . Managers heads . I think it was indefensible managers heads . I think it was indefensible there managers heads . I think it was indefensible there was managers heads . I think it was indefensible there was such indefensible there was such an extraordinary delay, in acting and investigating and i think it was grotesque that the doctors were made to apologise to lucy letby. I do thihk to apologise to lucy letby. I do think that to apologise to lucy letby. I do think that it was very typical of all the think that it was very typical of all the nhs cases of Whistle Blower, that managers resisted and attacked Whistle Blowers, basically. This isnt Whistle Blowers, basically. This isnt new. Whistle blowers, basically. This isnt new, this is what happens to many isnt new, this is what happens to many Whistle Blowers and not just in the nhs many Whistle Blowers and not just in the nhs it many Whistle Blowers and not just in the nhs. It is not, it is not novel, it is hot the nhs. It is not, it is not novel, it is hot ewe the nhs. It is not, it is not novel, it is not ewe narcs it isjust what happens it is not ewe narcs it is ust what ha ens. , ,. , happens. Even though whistleblowers are protected happens. Even though whistleblowers are protected by happens. Even though whistleblowers are protected by law, happens. Even though whistleblowers are protected by law, in happens. Even though whistleblowers are protected by law, in which happens. Even though whistleblowers are protected by law, in which ever are protected by law, in which ever sector they work in, most workers are supposed to be protected. Again, no, that is are supposed to be protected. Again, no. That is not are supposed to be protected. Again, no, that is not true, are supposed to be protected. Again, no, that is not true, uk no, that is not true, uk Whistle Blower law is very, very weak. Whistle blower law is very, very weak. And Whistle Blower law is very, very weak, and it is far behind most law in other weak, and it is far behind most law in otherjurisdictions, most people think in otherjurisdictions, most people think that in otherjurisdictions, most people think that uk Whistle Blower law protects think that uk Whistle Blower law protects them but it doesnt, there is no protects them but it doesnt, there is no proactive legal duty to protect is no proactive legal duty to protect Whistle Blowers, conferred protect Whistle Blowers, conferred if protect Whistle Blowers, conferred if on anybody, there is only. The uk law if on anybody, there is only. The uk law only if on anybody, there is only. The uk law only allows Whistle Blowers to sue uk law only allows Whistle Blowers to sue retrospectively, for financial to sue retrospectively, for financial compensation, after the fact and financial compensation, after the fact and long after the damage has been done. So, the law need changing so that been done. So, the law need changing so that there is a proactive requirement, on bodies to protect Whistle Blowers. Gk, requirement, on bodies to protect whistleblowers. Requirement, on bodies to protect whistleblowers. Ok, so you want to see the liege whistleblowers. Ok, so you want to see the liege lacing whistleblowers. Ok, so you want to see the liege lacing strengthened. See the liege lacing strengthened. James walker when you look at other public inquiries, whether it is mid staffs or the Maternity Death December at nottingham, there is this theme, a Common Thread through many of them, that leader, boss, managers the Executive Board dont listen, whether it is to their own staff, whether it is to patient, whether it is to relatives, is there something within nhs culture, that is the issue here or is it to do with managers, the managerial level . I think that you are quite right, there a common theme through it all, it is often the families that suffer, that bring the attention of the problems to the powers that be, that inquiries are carried out and is parliament too late what is important i think, that managers again, as i said earlier want to hear good new, they want to believe the trust is good, and is doing the right thing, what they dont want to do is hear bad new, the other hand the trusts that do well are the ones that want to be the best they can, and if they want to be the best they can, that means they have to investigate all the problems that occur and listen to people who are call Whistle Blowers but in fact are fulfilling their registration duty by bringing up concerns they have about clinical practise. But managers about clinical practise. But managers are about clinical practise. But managers are leader, they are supposed to lead, and 0k, they may not want to hear bad news but if 13 babies have died, that is horrific and you have to do something. It is, its a no brainer, obviously. Yes. Its a nobrainer, obviously. Yes, but one of its a nobrainer, obviously. Yes, but one of the its a nobrainer, obviously. Yes, but one of the problems its a nobrainer, obviously. Yes, but one of the problems is, its a no brainer, obviously. Use but one of the problems is, and i dont disagree with you at all, one on the problems is managers in the nhs are not necessarily leaders and what needs to be brought this is a system where there is an automatic response to events that occur, so investigations are carried out without the need of Persuading Managers who are necessarily skilled in assessment of risk and patient safety, so that, they can be bypassed from the Point Of View of investigations being carried out. Would you agree with that minh alexander, you almost take the Decision Making out of the hands of the manager, and when Something Like this, when paediatricians, consultants whoever raise issue theres is an automatic triggers of a process to bring in the Torsion Thatjames Walker A Process to bring in the torsion that james walker worked for, the Health Service Investigations Branch . ,. , Health Service Investigations Branch . , branch . There does need to be some form of independent branch . There does need to be some form of independent Review Branch . There does need to be some form of independent review of form of independent review of serious form of independent review of serious concerns that kicks in at some serious concerns that kicks in at some point serious concerns that kicks in at some point. Because internal investigations are in effective, in where investigations are in effective, in where serious Whistle Blower where serious Whistle Blower concerns where serious Whistle Blower concerns are, are concerned. Where serious whistleblower concerns are, are concerned. Right. Do ou concerns are, are concerned. Right. Do you think. Concerns are, are concerned. Right. Do you think, james concerns are, are concerned. Right. Do you think, james walker, concerns are, are concerned. Right. Do you think, james walker, there l do you think, james walker, there is a possibility that former managers could be held liable in some way . Criminally liable . Criminally liable . I think they miaht criminally liable . I think they might be. Criminally liable . I think they might be. I criminally liable . I think they might be, i dont criminally liable . I think they might be, i dont think criminally liable . I think they might be, i dont think that i criminally liable . I think theyj might be, i dont think that is something which i am particularly interested in, what i want to do, and to lead is to trying to make sure these things dont happen again, and i think. Haifa sure these things dont happen again, and i think. Sure these things dont happen again, and i think. How often have we heard that . Again, and i think. How often have we heard that . Accept again, and i think. How often have we heard that . Accept that again, and i think. How often have we heard that . Accept that as again, and i think. How often have we heard that . Accept that as well, | we heard that . Accept that as well, but think there we heard that . Accept that as well, but think there has we heard that . Accept that as well, but think there has been we heard that . Accept that as well, but think there has been change, i but think there has been change, there is new movement within the Department Of Health to pry and imtrove it Buzz It Doefrnt Go far enough, there needs to be good investigations by properly trained investigators, with Safety Science back up so we can look at the patterns and work out why things occur. The example in this case, was that 0k, occur. The example in this case, was that ok, the paediatricians had concerns but the family had concerns, other staff had concerns but there was no joined up thinking because there was no investigation of all the events would have brought the things together n the police with their different powers could find out more information, so that is an campi. Le of the fact it is not a simple lets investigator, it is investigating fully and properly with all the right people involved. Minh alexander, i wonder if you think if managers could be criminally liable, would that focus minds more . Minds more . Definitely. This is a ureat minds more . Definitely. This is a great failing minds more . Definitely. This is a great failing in minds more . Definitely. This is a great failing in the minds more . Definitely. This is a great failing in the nhs, minds more . Definitely. This is a l great failing in the nhs, managers are not great failing in the nhs, managers are not subject to any form of regulation comparable to the way in which regulation comparable to the way in which clinicians are regulated. This was a which clinicians are regulated. This was a recommendation of the bristol heart was a recommendation of the bristol heart Public Inquiry r over 20 years ago. Heart Public Inquiry r over 20 years ago. That heart Public Inquiry r over 20 years ago, that the government and nhs senior ago, that the government and nhs senior managers have been dodging this bullet senior managers have been dodging this bullet ever since then, there was an this bullet ever since then, there was an opportunity to revisit this in 2019. Was an opportunity to revisit this in 2019, when tom cox council for, provided in 2019, when tom cox council for, provided a in 2019, when tom cox council for, provided a report that are provided a Disbarring Mechanism to remove senior a Disbarring Mechanism to remove senior nhs a Disbarring Mechanism to remove senior nhs managers who had been found senior nhs managers who had been found to senior nhs managers who had been found to be guilty of serious misconduct, but, nhs england and the government dragged this out, and they recently, they came to the conclusion, that they would reject this vital. Conclusion, that they would reject this vital, vital recommendation, so, this vital, vital recommendation, so. We this vital, vital recommendation, so. We now this vital, vital recommendation, so, we now have no means of removing nhs managers who have failed seriously, which leaves unprotected. Thank seriously, which leaves unprotected. Thank you seriously, which leaves unprotected. Thank you very much. Hank you for talking to us, minh alexander, james walker, thank you for your time. The current Medical Director of the countess of Chester Hospital has issued a statement saying in two days time, england could make history by winning the world cup. But irrespective of whether the lionesses beat spain in the final in sydney on sunday, theres a generation of young kids right around the country who are setting their sights on trying to emulate what this england side have achieved. Commentator absolutely sublime there is a buzz in the air. Woke up in the night, i was dreaming. England is in the final. Thats right england is in the final. After winning in europe last year, all hopes are on the mighty lionesses defeating spain to bring the world cup home. Here in liverpool, im here for a kick around with this group of 7 to 11 year olds, learning the beautiful game. I love that, like, its always really exciting and the fans are always there to support them and everything, and theres a lot that i can learn off the games. According to uefa,2. 1i million more women and girls in england are participating in football since last years euro win, and that trend can be seen here in liverpool. Theyre just winning all the time, and itsjust inspiring, because, like, i want to be like them when i grow up. I want to be a football player. England mens arent winning and the womens are she laughs amy, the first teams manager, says that some hurdles have been eroded for young girls to play football, and its no longer seen as an oddity, as they entered the Mainstream Arm of the sport. Ive been at this club for ten years now, and when i first arrived, we had a couple of senior teams and a couple of girls teams, and over the last two years, weve now got pretty much an age group for every girls team across the board up to senior football, so that just goes to show that, really, in ten years, maybe even less than that, weve managed to grow our club. I think theres still room for sponsorship to be more involved in the womens side of the game. I think thats something that weve struggled massively, to get people to sponsor us, and obviously, we are a Grassroots Team that really does need that sponsorship, but you are seeing more now that businesses want to be involved in the womens game. For decades, the male teams have provided role models, but now, these Young Children have their own sportswomen to stick on their bedroom walls. Whos your favourite player, beatrice . I like mary earps and russo. Tell me why. This is bbc news. We will have the headlines for you at the top of the hour, which is strict after this programme, which contains upsetting themes. A nurse has been convicted of murdering babies. Its just beyond your imagination that somebody� s on a ward killing babies. Its unbelievable. So what turned lucy letby into a Serial Killer . Shes a difficult one to work out. Because shes emotionless. There was no empathy or. Or sympathy with whats going on at all. For the first time, we hear from the parents whose baby was murdered. I think shes a hateful human being. Shes taken everything from us, absolutely everything. The doctor who tried to raise the alarm. It was quite clear that they didnt think it appropriate to go the police at that stage. And the friend whos stood by her. She would only everi want to help people. To say that she could have harmed any baby, um, itsjust not in her nature. We reveal how Hospital Bosses protected lucy letby. The reputation of the organisation and protecting that reputation was a big factor in how people responded to the concerns raised. And how it was the doctors who stopped the murders. Its unprecedented
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