Dr Svilena Dimitrova@NeoDoc11
When I first heard about Lucy Letby's case, I had no reason to doubt the allegations against her. I began following the case because, as a neonatologist with a further interest in risk management and patient safety, I felt I needed to understand how it could possibly happen that someone could murder or attempt to murder any babies on my unit without anyone seemingly noticing or doing anything about it. I worried - could this have happened to me and my colleagues? And I hoped if it had, we would have noticed and acted on it properly much sooner.
As I followed the case via the media, I became increasingly confused by the medical evidence being presented. At first, I assumed the journalists simply didn’t understand the expert testimony and were not reporting correctly - surely no one could genuinely believe claims as medically absurd as babies being murdered by injecting air into a nasogastric (NG) tube? I had this conversation with many colleagues - Neonatal consultants, doctors in training and neonatal nurses. We were all really shocked by what was being reported. But I decided to wait until after the trial concluded before forming any real opinion as it was only then that enough information would become available that would make it clear as to what was actually said.
After the convictions, like many of my colleagues, I sat down to watch the interview with aspiring TV star doctor Ravi Jayaram. My jaw dropped as I heard his appallingly misleading statements about extubation made on national television. I have still kept the messages I exchanged with Neonatal colleagues that evening. All of us who watched were saying - surely he didn't just say that the only possibility for a 25 weeker to have extubated was for it to have been done deliberately? I cannot even begin to explain how absolutely ridiculous that statement is. The sensational manner in which it was also delivered immediately made me ask myself - did I make a cognitive error in assuming no actual real doctors could have said the medical nonsense reported by the journalists? Is it possible that the experts and medical witness doctors involved really have said things that were so ridiculous in court and got the judge and jury to believe this nonsense?
I then started looking through the information publicly available post-trial and I discovered that yes, this kind of flawed medical reasoning had indeed been accepted as fact. I was really shocked and decided to speak up, which I did as soon as the media gag was lifted. Thank you to Felicity Lawrence @guardiannews for making me feel safe to speak up.
At the stage when I first spoke up, I still didn’t know whether Lucy Letby was innocent. What I did know, however, was that the medical basis of her conviction was deeply flawed. I also knew - but this is due to my law degree rather than me being a Neonatologist - that there were multiple legal reasons for why this conviction was unsafe as well. However, I wasn't as interested in this as I wouldn't want for someone's sentence to be quashed on legal grounds if they were genuinely guilty. It remained possible, as far as I could see, that Letby had harmed the babies. What was certain, however, was that if she did, she certainly didn't do it in the way that was claimed. However, it stands to reason that a serial killer could more easily operate in a unit where substandard care was the norm - when overall competence is low, people are far less likely to recognise when something is seriously wrong - something I know very well from personal experience of being a clinician dealing with risk, and having worked for the CQC and the Ockenden inquiry.
After some time, I was instructed as an expert in the case. I took some annual leave and temporarily left the Ockenden review so I could give myself some time to properly look through everything. I then discovered many incidents of significantly substandard care with subsequent lack of insight by the clinicians involved and an almost complete absence of meaningful learning from mistakes. Unfortunately - neither of these are uncommon events in maternity and neonatal care these days. And neither is scapegoating someone. However - what was truly stunning in this case, and was definitely new to me at that point in time, was scapegoating via the criminally convicted serial killer route (usually people are just bullied out via employment tribunals, GMC/NMC and occasionally via the criminal courts for Gross Negligence Manslaughter route).
For one year now, I have lived with the knowledge that a committed hard working competent nurse is in prison for crimes that never happened, whilst the doctors responsible for very poor care remain celebrated as “heroes” and continue practising without consequences. And the medical experts also continue to practise with no consequences.
Putting this out here for the record. Not much else I can do. Thank you so much to @drphilhammond for continuing to expose this disgraceful MoJ.
@drphilhammond @legalmarkmc @DavidDavisMP @DavidRoseUK @PeterElston1 @Michelehal7344 @reasonoverfear @DOckendenLtd @wesstreeting @PrivateEyeNews @Jeremy_Hunt @MartynPitman @Voice4theDead
