In this episode, Michael and Peter complete their discussion of the RCPCH service review. They focus on a stark contradiction, namely that because deaths were expected, consultants did not report them to the Child Death Overview Panel , and yet their line later was that the deaths were unexpected.

Michael and Peter discuss RCPCH review findings that not only was there insufficient senior medical cover at The Countess but there was also reluctance to seek advice, whether among junior doctors or consultants. Was this because proceedures were weak or they weren't being followed? Michael cites an example from his own experience.

The RCPCH service review determines that staffing numbers and competencies at The Countess were inappropriate for the acuity of the babies being cared for. In this episode, Michael and Peter discuss this issue and possible reasons for the increased acuity in 2015 and 2016. However, the discussion soon turns to the bigger question of why the consultants did not use the Child Death Overview Panel to report deaths as early as June 2015, and their concerns about them, as they should have done.

The RCPCH reviewers consider whether The Countess' neonatal unit is compliant with current professional standards. The answer is a resounding 'no'. Is it really any wonder there was an increase in mortality and collapses? Non-compliance plus lower birthweights plus higher activity plus sewage equals....?

According to the prosecution medical witnesses at trial, it was Letby injecting babies with air which caused the skin mottling and collapses, leading to resucutation being required. And yet six years earlier the consultants told the RCPCH service review team that the mottling appeared "after a few minutes of resucitation". Is this a smoking gun?

Neonatal lead Stephen Brearey has suspected Lucy Letby for over a year when, in July 2016, he conducts further in-depth analysis into activity and acuity on the unit since June 2015. Brearey concludes that there was higher higher activity and lower admission birthweight than average during the period corresponding to the increase in mortality but does not consider it to be significant enough to explain the increase. Isn't that what he would say?

Paediatric consultants at The Countess have suspected Lucy Letby for nearly eight months so a broader meeting of senior doctors is convened to review 10 deaths since June 2015. A review of the nursing observations, staffing and junior doctor rotas for the 12 hours before the deaths is conducted and no link between the deaths and Lucy Letby is identified. However, a number of recommendations, such as new UVC guidance, are made.

The Royal College of Paediatric and Child Health (RCPCH) has been “invited to review the investigations of each death and the wider service, including network support and advice, protocols and transfer arrangements, to provide a view on whether there were any contributory factors in the deaths or missed opportunities to take action that could have prevented or mitigated them”. The report identifies failings on the unit and makes 22 recommendations that it said should be implemented before a reinstatement of the unit as an LNU should be considered.

Following the deaths of two triplets in June 2016, The Countess invites The Royal College of Paediatrics and Child Health (RCPCH) to conduct a service review of its neonatal unit “following re-designation from level 2 Local Neonatal Unit (LNU) to level 1 Special Care Unit (SCU) in July 2016 due to concerns about increasing neonatal mortality”, a downgrade that means the unit no longer admits higher risk babies under 31 weeks gestational age. The review is published in February 2017 and presents a catalogue of failings on the unit. In this episode Michael and Peter begin to discuss the RCPCH report.

Lucy Letby’s diaries are found during a police search of her addresses. They purport to contain a chilling code used by Letby to denote the days on which she attacked babies. However, it turns out that the letters that the police thought were “LO” are in fact “LD” which is a common acronym used by nurses that stands for “Long Day”. Post-it notes were also found on which Letby had scribbled “I am evil” and “I killed them on purpose”. Was Letby confessing to crimes or did her notes have another explanation?