Lucy Letby Triplets to Singletons
- Sarah Hawkins
- Jul 18
- 6 min read
Updated: Jul 20
People may be aware that I have been working with Professor Richard Gill over the previous months looking into the overlooked subject of the twins and
multiples in the Letby case. This has in turn caused me to find areas of further concern in the care of the singletons. This blog, while inspired by looking at the Triplets O, P and their surviving triplet often referred to as R, has opened up questions relating to the singletons also.
There has been a persistent concern for me regarding the Lucy Letby case, stemming from both the prosecution and defense perspectives. While the prosecution's focus has narrowed to one individual and potentially three members of management, the defense is scrutinising other individuals, teams, or even one hospital. The recent announcement of further investigations into baby deaths at Liverpool Women's, potentially linked to the Lucy Letby case, has prompted a deeper examination of the broader context.
Research into the triplets' case specifically has raised broader questions concerning pregnancy care decisions, not only for these triplets and twins but also for other babies. The testimony of the triplet parents to the Thirlwall inquiry provides key insights. They stated that the consultant at the Countess of Chester Hospital referred the mother to Liverpool Women's Hospital for a second scan, yet assured them he was content to continue care at Chester, with the option to refer back to Liverpool Women's if problems arose. The parents found the Countess of Chester more convenient and accepted this plan. At Liverpool Women’s Hospital, they were informed that one triplet was smaller and, as all three shared a placenta, were offered the option of stopping the smaller triplet's heartbeat to improve the survival chances of the other two. They declined this option which is just as well as the smaller one is believed to be the only survivor.
This seemingly patient choice is highly questionable given that the parents were unaware of the increased mortality rate at the unit in 2015 and 2016 until police contact a year later, and only learned of the nurse's removal during her criminal trial in 2023. Legally, this lack of full information precludes true patient choice.
Further scrutiny arises from information suggesting that hospital targets and research initiatives between 2014 and 2017 may have inadvertently de-prioritized patient safety. The 'Liverpool Women's Annual Report and Accounts for the year ended 31 March 2015' indicates that while antenatal care for multiple pregnancies at LWH adhered to NICE Guideline 2011 standards, it was recommended that LWH proformas, particularly for 'Place, Timing and Mode of Delivery (PTMD)', be encouraged. Midwives and obstetricians in the Multiple Pregnancies Clinical team were advised to use these forms. This suggests a recognition of the significant consideration required for twin and multiple pregnancies, even generally speaking.
The triplet pregnancy was, conservatively, a 1 in 100,000 occurrence but they are thought to be much more rare. All triplets shared a placenta, and the selective reduction (termination) of the smallest, believed to be Baby R (the sole survivor), that was offered, is standard practice even in triplet pregnancies as well as complete termination of pregnancy even where all of the fetus’ are equal size and have their own placentas due to the high risks associated. Many women having a shared-placenta twin pregnancy are also offered this. Therefore, a woman choosing to continue such a challenging pregnancy would presumably desire three healthy babies. It is highly unlikely that a mother with complete understanding and comprehensive and accurate information would choose not to travel up to an additional 45 minutes give or take for potentially better care. It is evident that in 2016, the Countess of Chester Hospital recorded a higher number of high-risk multiple pregnancies. This raises the question of whether this was a consequence of evolving care pathways between the two hospitals, particularly in light of LWH's internal targets.
Liverpool Women’s NHS Foundation Trust's Quality Strategy for 2014-2017 aimed to ensure that "no more than 10% of live births are multiples". This document also articulated the trust's intention to improve neonatal mortality, specifically "To deliver our risk adjusted neonatal mortality (deaths within 28 days of birth following a live birth) within 1% of the national Neonatal Mortality Rate". Furthermore, it aimed "To reduce the incidence of stillbirths attributed to Small for Gestational Age (SGA) by 20% by early implementation of the NHS England saving babies’ lives care bundle," with ongoing audits to track reductions in this category.
The objective to reduce stillbirths attributed to SGA impacts all pregnancy types, including singletons. Notably, of the babies in the indictment, at least 8 out of 17 pregnancies (12 out of 17 babies) were affected by SGA, and 5 out of 9 of those pregnancies (8 out of 12 of those babies) received some care at Liverpool Women's, including all 4 multiples affected by diseases that are diagnosed by among other things SGA. This prompts inquiry into the adherence to the previously mentioned proformas.
The Trust's 2015-16 Quality Report reiterated that reducing the incidence of multiple births was a priority due to associated risks of preterm birth and developmental issues. This report highlighted LWH's low multiple live birth rate, meeting the Human Fertilisation & Embryology Authority (HFEA) target of 10% for fertility centers. It is unclear whether data collection for this target was isolated to the fertility center or encompassed general births.
Both Liverpool Women's and the Countess of Chester Hospitals participated in relevant national clinical audits during this period, including the Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK)
Perinatal Mortality audit. LWH submitted 100% of cases in 2015-16. However, the Countess of Chester did not submit its data. Liverpool Women's had incentives to do so, including opportunities to join networks of centers of excellence and receive grants and bursaries, such as one from the Twins Trust (formerly TAMBA) between 2016-17.
In 2014, Wellbeing of Women awarded a £1 million 'Harris Research Grant' for premature babies, which opened in May 2015 and was extensively promoted by lead clinicians. Television shows, including an
ITV documentary titled 'The Triplets Are Coming,' and Channel 4's One 'Born Every Minute' further promoted Liverpool Women's as a center capable of caring for vulnerable pregnancies.
Liverpool Women's proudly stated in its 2015-16 audit that its neonatal mortality rate for booked births was below the national rate at 2.1 deaths per 1,000 live births. Even when including babies transferred for specialist treatment, their rate remained within 0.4% above the national rate, within the Trust's target of 1%. Yet they transferred out, this statistic is not included. The importance of strict adherence to "improving" trust numbers becomes apparent when considering the financial incentives: in 2015-16, the total monetary value of income conditional on achieving quality improvement and innovation goals was £1,977,598, similar to the £1,955,007 received in 2014-15.
Given the numerous questions and target-driven motivations, it becomes challenging to solely attribute blame to a small number of relatively non-influential individuals. The Countess of Chester's role in the care of multiple pregnancies is pertinent. While the initial triplet referral from the Countess where the mother was booked (a highly questionable fact) was to Liverpool Women's Hospital, the option to continue care at the Countess of Chester was presented and accepted. However, the parents' comments clearly indicate their decision was not informed, suggesting a potential shift or flexible approach to managing complex pregnancies between the two institutions.
Finally, the 'Quality Strategy Liverpool Women’s NHS Foundation Trust 2014-2017 Version 2 February 2015' outlines that, from April 2014, a new equality measure required providers to submit evidence that any service redesign or cost improvement initiatives had undergone an equality impact assessment report, reviewed quarterly by clinical commissioning groups. This mandates that any service changes must consider their impact on patients, service users, and presumably staff. Our ongoing research necessitates further investigation into the decision-making processes and inter-hospital dynamics concerning triplet and other multiple pregnancies during this period.
Sarah Hawkins
Google Docs spreadsheet containing much of the information used in this post:
Spreadsheets link
Disclaimer
The work I am undertaking with Professor Richard Gill is on a pro-bono basis. This is in keeping with all the work I have done with families who have experienced the loss of a baby, which has been done without charge.
If you would like to support my ongoing efforts and help subsidize my work, you are welcome to make a donation to my PayPal account. Your contribution will help me continue to offer this support to families and continue my work with Professor Gill.
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