Lucy Letby is accused of giving a potentially lethal dose of morphine to a newborn baby two years before she committed her first murder, an inquiry has reported.
In July 2013, the infant received ten times the correct dosage of the painkiller during a night shift. Fortunately, colleagues identified the mistake an hour later during a handover, potentially saving the baby’s life.
The Thirlwall inquiry is investigating the circumstances surrounding Letby’s actions at the Countess of Chester Hospital. The inquiry revealed that Letby and another nurse had set up the morphine infusion for the newborn.
The colleague involved in the incident was reportedly so shaken that she considered resigning. However, Letby expressed her frustration when informed by the neonatal unit’s deputy ward manager, Yvonne Griffiths, that she could not administer controlled drugs until a review was conducted.
A week later, the neonatal unit’s manager, Eirian Powell, allegedly told Letby she could continue working with medications like morphine. The next day, Letby sent a message to a colleague stating, “Thankfully, Eirian felt it had been escalated more than it needed to be. Everything is back to how it was. I just have to have more training on using the pumps, and it will be on my record for six months. She was very supportive. It’s a case of learning to live with it now and getting my confidence back. I’m on nights this week, still feeling a bit vulnerable and thinking ‘what if,’ but I’ll get there in time.”
Inquiry counsel Nick de la Poer KC asked Griffiths, “Did you escalate it more than it needed to be?” Griffiths responded, “No.” She explained that Powell was on annual leave when she learned about the “very serious” morphine incident.
Griffiths added, “If that had not been picked up as soon as it was, it might have led to the baby’s death.” When de la Poer asked, “Could have been fatal?” Griffiths confirmed, “Yes.”
When asked about Letby’s reaction to the error, Griffiths noted, “I remember the other lady was very distraught and upset to the point where she was going to leave nursing. Letby seemed upset but not to the same extent. She appeared to accept my decision but might have thought I was being a bit harsh.”
An action plan required Letby to complete additional training on infusion calculations with practice development nurse Yvonne Farmer before she could work with controlled drugs again. However, this training did not occur until September 2013, according to the inquiry.
Richard Baker KC, representing some families of Letby’s victims, suggested, “One interpretation is that Lucy Letby went over your head, complained about your decision, and you were overruled. If that is the conclusion, would you see it as manipulative behavior?” Griffiths replied, “I suppose it shows a very overconfident nurse. Part of a nursing journey is to learn from mistakes. I found that inappropriate and agree it was quite manipulative.” Baker then remarked, “Quite grandiose and arrogant as well, isn’t it?” Griffiths agreed, “It is, yes.”
Another dosing error by Letby was noted in April 2016 when she administered an antibiotic that had not been prescribed. Farmer described this as “not a minor error, possibly a major error,” but Letby believed it was “unavoidable.”
Reflecting on the incident, Letby stated, “The mistake was realized immediately by myself and a colleague after the dose had been given. My initial concern was for the baby’s safety. The registrar was informed, and measures were taken to ensure the infant was monitored and that no harm occurred.
“While not excusable, my colleague and I were administering multiple antibiotics due at similar times while caring for our own patients and supporting junior team members, including a newly qualified nurse, during a time when the unit lacked adequate staffing.
“Looking back, I feel the situation was unavoidable and that care was given to the best of our ability. However, knowing how circumstances could have affected the process of administering antibiotics, I should have been more vigilant and made greater efforts to ensure all relevant checks were completed before giving the medication. I also should have prioritized my time more effectively.”
Letby, 34, from Hereford, is currently serving 15 whole-life orders after being convicted at Manchester Crown Court for murdering seven infants and attempting to murder seven others between June 2015 and June 2016.
The inquiry is expected to continue until early 2025, with findings anticipated to be published by late autumn of that year.
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