Abstract
On 18th August 2023, 1 neonatal nurse, Lucy Letby, was found guilty at Manchester Crown Court, United Kingdom (UK), of murdering seven babies and attempting to murder six more. Between June 2015 and June 2016, Letby deliberately injected babies with air, poisoned two of the babies with insulin and force-fed others milk. She was arrested for the offences in July 2018 and charged in November 2020. The trial began in October 2022 and lasted 10 months, one of the longest murder trials in UK history. Letby maintained her innocence throughout the trial, pleading not guilty to the charges. Once the verdict had been delivered, she refused to attend the sentencing hearing where victim personal statements from the parents of the children murdered were read out to the court. She was sentenced to life imprisonment, with a whole life order. This means Letby will never be eligible for release from prison during her lifetime. She is one of only four women in UK history to be sentenced in this way, marking the gravity of the offending in this case.
Much has been written, in the short period since the guilty verdicts were made public, exploring the many complex issues raised by the case.2–6 Inevitable parallels have been drawn between the case of Letby and that of Dr Harold Shipman 7 who was convicted in 2000 of murdering 15 patients whilst working as a General Practitioner. Another comparison is with Beverley Allitt 8 who was convicted of murdering four children whilst working as a nurse on a children’s ward. Other murderers who were nurses include Colin Norris and Victorino Chua who also used insulin to murder vulnerable patients 9 and Benjamin Geen 10 who used dangerous drugs to cause his patients respiratory arrest only to then enjoy the thrill of resuscitating them. There is also the disturbing case of Barbara Salisbury who was found guilty of attempting to murder her patients with the aim of ‘freeing up beds’. 11
In each of these cases, it is clear that their occupation as a health care professional and in particular a nurse provided them with the opportunity to attempt to kill their patients and tragically, very often, succeeding. Nurses often going about their duties on a busy hospital ward are never going to be very closely monitored, and of course they are very often caring for the most vulnerable who are very sick and infirm hence them being in a hospital. Field and Pearson (2010) 12 note that ‘The murder of a patient or patients by a nurse might occur in any setting in which nurses care for vulnerable patients’ confirming that the site of the offence often provides much opportunity for the offending to take place. These sites have been referred to as ‘crucibles’ to recognise this. In Letby’s case, she often worked the night shift and was ‘was willing and wanting to do extras’ 13 which ensured she had access to the unit more often than normal.
It is also accurate to conclude that the signs for concern are often quite obvious in these cases.14,15 It is colleagues, who work closely with the killers, who become suspicious of irregular practices or predictions of illness or death that are unfounded. These colleagues often raise concerns at a relatively early stage but are often dismissed or the concerns become submerged in grievance and complaints paperwork and a range of labyrinthine management processes. As a result, colleagues may be deterred from raising concerns for fear of accusations of bullying and harassment leaving organisations to reflect, or not, on the missed opportunities after the event for stopping these killers in their tracks and then being reminded of their own culpability in what unfolds. In Letby’s case, the alarm was raised on a number of occasions from as early as October 2015 by doctors who worked with her. The director of nursing and board safeguarding lead, the medical director and the associate director of nursing were all notified, but Letby continued working until June 2016 when she was finally removed from clinical duties. It wasn’t until May 2017 that the hospital trust decided to call in the police to investigate. More alarmingly, a doctor testified in the trial to confirm that he had been pressured ‘not to make a fuss’. 16 The hospital trust did take action ordering two formal external reviews into the spike in deaths at the unit and removing Letby from the ward (realising she was the only staff member present during the sudden collapses and deaths of a number of premature babies). A hospital executive instructed senior doctors, who had raised concerns about Letby, to write a letter of apology for raising concerns about her practice. This action was prompted by Letby’s parents threatening to refer the doctors to the General Medical Council for removing her from the neonatal unit. 17
It is noted that the two external reviews never examined whether Letby or others were responsible for the deaths, but they did recommend further investigations which did follow. What becomes clear often with the benefit of hindsight is that killers, such as Letby, are often aided by investigations that are often incomplete or at worst ‘incompetent’. 7
A common theme discussed in the post Letby conviction has been reference to how ‘evil’ both her actions and/or she is. This is a common response in these instances
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and was emphasised in this case because police had discovered a handwritten note by Letby which she was cross examined on during her trial. The note stated where she stated, ‘I am evil, I did this’. Such constructions are not unusual in these cases and are usually linked to how unfathomable the actions are because: The incomprehensibility of a nurse that murders patients is shared by both by the public and by the nursing profession. For the public, it is a defence because they will inevitably find themselves in the care of nurses. For nurses, it is a phenomenon so at odds with their core business that it is beyond contemplation.
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Linked to this lack of comprehensive is the need to understand why? In Letby’s case, one of the media opinion pieces spoke of how when we are faced with evil like Lucy Letby’s we ‘yearn for a rational explanation’.
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In the discussion, it is noted that her external image did much to persuade colleagues and patients alike that this could not be due to her actions. As Toynbee explains: Coming from a gentle-faced nurse, the sort who might grace recruitment posters for the most trusted among all professional, multiplies the shock. Tradition, culture and a measure of sexism expects nothing but care and kindness from an 'angel'. 'It can’t be Lucy, not nice Lucy', the head consultant on the hospital unit said, even as he connected Letby to the series of unexplained baby deaths for the first time.
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But we are reminded that evil need not be apparent nor astounding, and given how ‘beige’ and ‘average’ Letby was perceived to be, 20 commentators have been reminded of Arendt’s work (1963) on the ‘banality of evil’ 21 and asked whether one can do evil without being evil? 22
We ask then what next in this unfolding tragedy? The UK government has announced a statutory inquiry which will consider the circumstances around the crimes which were committed by Letby.
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This will mean the inquiry has legal powers to compel witnesses and it must be heard in public. It is at this point we are reminded that tragedies such as these and other shocking events in the UK National Health Service have often had inquiries before, both statutory and non-statutory. Lessons learned are presented routinely as a way of momentarily believing this will not (or should not) happen again.
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Toynbee notes that although such inquiries are important for the families, we should ensure we do not overreact with yet more recommendations and promises of ‘never again’
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because this will be a promise we can never fulfil. As Field and Pearson (2010) note from the Allitt inquiry: ‘…a determined and secret criminal might defeat the best regulated organisation in the pursuit of his or her purpose’ and ‘…no measure can afford complete protections against a determined miscreant.
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What is perhaps critical is the need not to react in the usual knee-jerk way. We are reminded of the work of Gallagher (2020) 26 and the need to be slow and reflective in our response. Of course, it is critical to denounce and deplore such actions, but for organisational change to really take place where the opportunities for such horrific acts are minimised, we need to also demonstrate a commitment to the principles of slow ethics as they could apply here: to understand, to repair, to sustain, to appreciate, to remember and to listen to people’s stories to ensure they feel listened to.
As for Letby, she continues to maintain her innocence, as she has done from the outset. As a result, we do not know, and may never know, the motivations for these awful crimes. She had already been suspended from the register and the Nursing and Midwifery Council have since announced their moving ahead to strike her from the register. 27 Letby begins her prison sentence knowing she will never be released. It is perhaps fitting to conclude that the parents of her victims confirmed in their victim personal statements, although she never heard them say this in person,28,29 ‘You are evil, and you did this'. 30