Problems at the Countess of Chester Hospital’s neonatal unit began before Lucy Letby’s time and created a “perfect storm” for care failings, a former senior nurse on the ward has claimed.
Speaking to Nursing Times, Michele Worden, a former advanced neonatal nurse practitioner (ANNP) at the hospital, described a unit “not fit for purpose”, citing mass redundancies of senior nurses, wards operating beyond capacity and an estate in disrepair during the early 2000s.
“You cannot run an intensive care unit with no senior nursing staff and really junior nurses”
Michele Worden
The claims come amid ongoing scrutiny of the Letby case.
Letby, 35, has been found guilty of murdering seven babies and attempting to murder seven others while working on the unit in 2015 and 2016.
She is currently serving multiple life sentences for these crimes and has made unsuccessful attempts to appeal.
However, there has been a growing chorus of people questioning her guilt.
The former neonatal nurse’s legal team has asked the Criminal Cases Review Commission to review her case and refer it back to the Court of Appeal.
It follows a report published in February by a panel of 14 international paediatric and neonatal experts, which claimed there was “no medical evidence to support malfeasance” in any of the cases heard at Letby’s trial.
Ms Worden has spoken to Nursing Times about the key issues that she witnessed on the unit, some of which predate Letby.
Joining the Countess of Chester Hospital in 1988 as a staff midwife, Ms Worden became a sister in 1990 and then one of the hospital’s first ANNPs.
In 1995, an article published in the Daily Post described Ms Worden as a “super nurse” who was set to improve the quality of care for hundreds of babies on the unit.
In the early 2000s, the Countess of Chester Hospital neonatal unit was operating at level three – the highest level of care for premature and critically ill newborns.
Often these babies will have been born before 28 weeks’ gestation, or be very unwell after birth. They may need support lasting more than 48 hours.
Ms Worden noted that, at this time, there was a vast skill mix of registered nurses on the ward.
However, she noticed that the seniority of nurses began to dwindle over the years that she was there.
“From about 2003 it became obvious that when a registered nurse left, they weren’t being replaced, or they were being replaced with nursery nurses,” she said.
“It got to the point where senior nursing staff were so twitched about this, they wrote a letter.”
In the letter, dated 28 June 2004 and seen by Nursing Times, 12 senior nurses from the neonatal unit wrote to executives at the hospital to raise concerns about “continuous unsatisfactory staffing levels on the NNU”.
The letter set out that staff wished the Countess of Chester to remain a high-level neonatal unit, but these aspirations were being “seriously threatened by a staffing crisis which has steadily worsened over recent months and shows no signs of abating”.
It warned that the continuous stress levels being endured by staff had “long since exceeded tolerable levels” and were leading to increasing sickness levels, exhaustion and rapidly declining morale.
The letter said: “If necessary, endless examples can be given of professionally unsatisfactory situations occurring as a result of our staffing situation by any of the signatories to this letter.
Michele Worden
“In our considered opinion the problem will only be resolved by more appropriately skilled people working clinically.”
A 2003 review of neonatal intensive care services, commissioned by the government, found that neonatal care across England was widely dispersed with limited capacity in the larger units.
Following the review, the 180 neonatal units in the English NHS were organised into 23 geographical clinical networks.
The Countess of Chester Hospital was brought into the Cheshire and Merseyside Neonatal Network, alongside Arrowe Park Hospital and Liverpool Women’s Hospital.
Between 2005 and 2006, it was decided that the Countess would become a level two unit, explained Ms Worden.
She alleged that this move resulted in hospital management stating that they did not need senior nursing staff as they were “not going to have sick babies”.
A level two unit is for babies who need a higher level of medical care and those born between 27 and 31 weeks’ gestation. They may require short-term intensive care, usually up to 48 hours.
Ms Worden added: “When I first qualified as the ANNP, they had me holding two premature babies [for a photo for a newspaper].
“They said I was going to be a ‘super nurse’ because I was the first nurse practitioner in the hospital.
“And then few years on, I’m being served compulsory redundancy, because of the cost cutting. It’s just a mess.”
Ms Worden was served compulsory redundancy in 2007, alongside several other senior nurses who were let go around the same time.
She alleged that, at the time, she went to a consultant paediatrician urging him to intervene.
The doctor allegedly responded by simply telling Ms Worden that it was a “nursing issue” and he had been “told to butt out”.
Ms Worden recalled telling him that: “You cannot run an intensive care unit with no senior nursing staff and really junior nurses.”
She added: “You’ve got more and more nursery nurses coming in, and they are being asked to look after babies who [are] above their capabilities [and] their training.”
Following the mass redundancies of senior nurses across the unit, there began an influx of recruitment of more junior nursing roles, according to Ms Worden.
She claimed that eight registered nurses had left the unit, and eight unregulated nursery nurses were brought in to plug the gap.
A year later, the unit then employed two newly qualified nurses, one of whom was Letby.
Ms Worden took her concerns about staffing to the local newspaper, the Chester Chronicle.
“During my final year at the Countess of Chester Hospital, I was appalled to observe the decimation of the nursing and midwifery service,” she wrote in the article, dated March 2011.
“The current management decision to dramatically increase the ratio of unqualified to qualified is forcing these unqualified staff into performing, or rather attempting to perform, tasks beyond their capabilities.
“The repercussions of all this, for the depleted numbers of qualified staff and ultimately for their patients, is profoundly worrying.”
Staffing issues on the Countess of Chester neonatal unit persisted many years later, including the period in which Letby was convicted of committing her crimes.
In December 2015, Dr Alison Timmis, a consultant paediatrician, emailed Tony Chambers, the hospital’s chief executive, reporting that staff were in tears because they were being forced to look after more babies than the unit could accommodate.
According to The Times, she wrote: “Over the past few weeks I have seen several medical and nursing colleagues in tears… they get upset as they know that the care they are providing falls below their high standards.
“This is not an exceptionally busy week. This is now our normal working pattern and it is not safe. Things are stretched thinner and thinner and are at breaking point.
“When things snap, the casualties will either be children’s lives or the mental and physical health of our staff.”
“Chester is no different than Shrewsbury, Nottingham, Morecambe Bay”
Michele Worden
A year later, in December 2016, neonatal unit manager Eirian Powell put forward a business case to the hospital to improve nurse staffing.
Ms Powell set out that the unit should employ 10 band 5 nurses, or two ANNPs, which would require the reduction of some band 4 nursery nurses.
In the document, she warned that the unit had 74% registered nurses versus 26% unregistered staff – the lowest proportion of registered nurses in the Cheshire and Merseyside Neonatal Network.
“The impact to patient care may be catastrophic leading to a multifactorial negative impact to the baby and the family,” the document said.
“The most junior nursing and medical staff are caring for the infants in transitional care and may not always be experienced enough to respond to clinical deterioration as quickly as registered staff.”
At Letby’s trial, the jury was told that the former neonatal nurse wanted to pick up additional shifts so she could have more time to harm babies.
However, Ms Worden said she believed the increase in mortality over the indictment period could be explained by other factors, including the increasing pressure on the unit and the crumbling estate.
She described how the neonatal unit was “falling to pieces” when she was working as an ANNP.
“One time we had an outbreak of tiny black… insects, and they had to call an exterminator in because they were coming through the ceiling,” she said.
“The sinks were always blocked up. The taps wouldn’t run properly.
“And that made life very difficult, because if you can’t wash your hands you have to walk out to another clinical area where you can wash your hands. So there was a lot of toing and froing.”
Ms Worden added: “It wasn’t just the neonatal unit that wasn’t fit for purpose, the whole maternity and paediatric and gynaecology… was not fit for purpose.
“The problems with the sewage and blocked sinks were not just [on] the neonatal unit, it was on the labour ward, it was all over.”
Similar concerns about staffing and estate were revealed in documents that were published by the Thirlwall Inquiry, which has been investigating the circumstances surrounding the events at the Countess of Chester.
Caroline Oakley, a band 6 nurse on the unit, said in her witness statement that there had been an increasing medical complexity of babies on the unit, including prematurity-related complications and other health issues.
Regarding Baby D, for whom Letby was convicted of injecting air into her bloodstream, Ms Oakley said she first thought a rash on the baby’s skin was related to sepsis.
Her statement set out that she recalled wondering whether the rash may have in fact “had something to do with the previous leak through the ceiling” in one of the nurseries at the hospital, which she said contained “soilage”.
More on the Thirlwall Inquiry
Overall, Ms Worden said the situation at the hospital was a “perfect storm” for things to go badly wrong.
“Everything was coming at once,” she said.
Ms Worden took to social media during Letby’s trial to discuss some of her experiences and concerns but was met with hostility.
“I got told that I was a baby murderer lover,” she said.
“When I started to put out [online] that I was the ANNP on the unit, I was told ‘you’re a liar, you’re going to end up with a brick through your living room’. It got really nasty.”
Even today, nurses at the Countess of Chester Hospital are “having a really bad time”, Ms Worden alleged.
“Lots of them have now retired or moved to other hospitals because they don’t want to be associated with Chester. It’s just been really, incredibly difficult on so many levels.”
At the trial, the prosecution questioned Letby’s motivations when she sent a sympathy card to grieving parents of Baby I, whom she was later convicted of murdering by inserting air into the baby girl’s stomach.
Ms Worden noted that the suggestion by the prosecution that sending a bereavement card could be “macabre” was “impacting neonatal nursing now”.
“The level of trust is gone,” she explained.
“The nurses don’t want to be sending christening cards or bereavement cards because, oh my god, are they going to point the finger and say that I’m Lucy.”
This echoed what Mark McDonald, Letby’s barrister, told Nursing Times earlier this year.
He said he had been contacted by nurses across the country who were “frightened” that “the finger could easily be pointed at them”.
Overall, Ms Worden described how the situation at the Countess of Chester was “no different” to other scandals that have been uncovered across NHS hospitals in recent years.
“The whole system from the top right to the bottom has to change,” she said.
“Hopefully Lucy will be exonerated. Chester is no different than Shrewsbury, Nottingham, Morecambe Bay. Women and children’s healthcare has never been a high priority.”
Nursing Times put all the claims in this article to the Countess of Chester Hospital for comment.
A spokesperson for the hospital said: “Due to the Thirlwall Inquiry and ongoing police investigations, it would not be appropriate to comment further at this time.”
