Hospital where Lucy Letby worked suffered bacteria outbreak ‘lethal’ to babies

Leaked risk report shows pseudomonas aeruginosa colonised taps in nurseries of neonatal unit

The neonatal unit where Lucy Letby worked suffered an outbreak of bacteria lethal to babies, a leaked risk report shows.
In August 2023, Letby was convicted of the murders of seven newborns and the attempted murders of six other infants. A retrial in July also found her guilty of the attempted murder of another child.
Since the conviction, numerous scientists, statisticians and doctors have expressed their concern about the evidence presented to the jury regarding shift patterns, medical conclusions and the standard of care at the Countess of Chester.
It has now emerged that at the time when infant mortality rates spiked at the Countess of Chester hospital between 2015 and 2016 – the years in which Letby was convicted of killing the infants – the bacterium Pseudomonas aeruginosa had colonised taps in the nurseries of the neonatal unit, including intensive care.
Pseudomonas is known to be lethal to vulnerable babies. In 2012, a premature baby died and 12 others needed treatment at Southmead Hospital in Bristol after an outbreak of a water-borne bacterium.
Three premature babies also died after contracting the bug at the Royal Jubilee Maternity Hospital in Belfast January 2012. In that case, sink taps were found to be the source of infection. A baby had died from the same infection six weeks earlier in Derry.
David Livermore, professor of Medical Microbiology, at the University of East Anglia said: “Pseudomonas aeruginosa is an environmental organism that likes moisture.
“It can be lethal in newborns, especially premature ones, who lack a properly-developed immune system.
“From mid-2015 to mid-2016 there were around 17 infant deaths at the Countess of Chester unit.
“We are asked to believe that this comprised two superimposed clusters, one of seven murders by Lucy Letby, and one where, to quote the crown prosecution expert, they died for the usual problems why small babies die: haemorrhage, infection, congenital problems.
“It is simpler to believe that we are looking at a single spike of fatal infections in a chaotic unit.”
The risk report leaked to The Telegraph, showed that the Countess of Chester hospital had been dealing with Pseudomonas since at least May 2015 when there were fears about transferring babies from nearby Arrowe Park Hospital.
The risk score was reduced in August 2015, when there had been no infections in neonates, but in December 2015, a tap in intensive care tested positive for the bug and had to be replaced.
In the same month a tap in another baby ward also tested positive but the report warned that there was no capacity to replace it, so filters were fitted instead. The report said the filters would remain in place “until we get the all clear”.
Notes show that by the middle of February 2016, staff had still not received this confirmation.
The risk of the bacteria was designated as high and the unit brought in controls to prevent the spread, including limiting visitors and treating all babies “as if they had a severe infection”.
The risk register said that although estate staff were monitoring the taps and testing the water supply frequently it was: “Only as good as the last test and does not guarantee the patient’s/parents/visitors or staff safety.”
The US Centre for Disease Control’s Prevention and Response branch told The Telegraph that Pseudomonas was “an urgent threat” to babies in intensive care, and warned symptoms of an infection could sometimes be subtle, and cause or exacerbate other conditions.
“In our experience mortality rates during Pseudomonas aeruginosa outbreaks can be high,” a spokesman said.
“Neonatal Intensive Care Unit patients often have defects in their immune system and are often subject to large amounts of very invasive care which make them very susceptible to infections with healthcare pathogens and also, when infected, at high risk for adverse outcomes including death and severe infection.
“As neonates have little capacity to compensate for additional stresses, infection can cause other problems in these patients that are not directly related to the infection.”
One mother whose baby was at the unit in 2016 said that she had been told that there was an outbreak of a virus on the ward, and her son was the only infant not infected. It is not known if she was referring to the Pseudomonas bacterial incident or a separate viral outbreak.
Speaking to the Mail’s Trial of Lucy Letby podcast, the anonymous mother said: “A matron came upstairs to me while I was an inpatient for two weeks and said that there was a virus on the unit and all the babies have got to stay in the rooms that they’re in and we’re not accepting any new babies.
“She seemed very panicked and it left me thinking at the time ‘oh my gosh, what is going on’?
“(My son) was the only one that apparently didn’t have this virus. They didn’t want him getting it because he was so small, he was still on the oxygen at the time.”
During Letby’s trial it emerged that there had been major problems with plumbing in the hospital and on one occasion human waste or sewage entered the neonatal intensive care room from the drains of a ward above.
However the bacterial infection problems in the unit were never mentioned, neither during the trial nor in a report by the Royal College of Paediatrics and Child Health (RCPCH) who investigated the high mortality rate at the unit in 2017.
Prof Livermore added: “Although the Pseudomonas colonisation was known at the time of the RCPCH report it is not mentioned. Why, especially given the Belfast deaths? Were they told?
“Did they speak to the Infection Control Team, given that infection was such a plausible cause of clustered deaths? These are yet more questions that the Thirlwall Inquiry needs to address.”
The Thirlwall Inquiry has been set up to look at problems at the Countess of Chester during the period where Letby was convicted of murdering babies.
The Telegraph has asked the Royal College of Paediatrics and Child Health whether it was informed about the Pseudomonas outbreak while it was investigating the high mortality rates, but it said it could not comment while the inquiry was ongoing.
A spokesman for the Countess of Chester Hospital NHS Foundation Trust said “Due to the ongoing police investigations and the pending public inquiry, it would not be appropriate to answer or provide advice on the questions asked at this time.”