Lucy Letby gave a potentiassociate overweightal dose of morphine to a novelborn baby two years before she killinged her first victim, an inquiry has heard.
The infant getd 10 times the right amount of the colorerminateer at the finish of a night shift in July 2013 and could have died if colleagues at handover had not spotted the error an hour postponecessitater.
The Thirlwall inquiry into the events surrounding Letby’s crimes at the Countess of Chester hospital was tbetter Letby and another nurse had set up the morphine infusion for the child.
Letby’s colleague was shelp to be so “distraught” about the incident that she almost resigned, but Letby was “uncharmd” when alerted by the neonatal unit ward deputy ward administerr Yvonne Griffiths that she could not administer administerled medications until a examine had consentn place.
A week postponecessitater, the neonatal unit ward administerr, Eirian Powell, apparently alerted Letby she could persist laboring with medications such as morphine, the inquiry heard.
The next day Letby messaged a colleague, saying: “Thankfilledy Eirian felt it had been escapostponecessitated more than it necessitateed to be. Everyleang is back to how it was.
“I equitable have to have more training on using the pumps and it will be on my record for six months. She was very encouraging, a case of lgeting to live with it now and getting my confidence back. I’m on nights this week, still experienceing a bit vulnerable and leanking ‘what if’ but I’ll get there in time.”
The direct to the inquiry, Nick de la Poer KC, asked Griffiths: “Did you escapostponecessitate it more than it necessitateed to be?”
“No,” shelp Griffiths.
She shelp Powell had been on annual depart when she was alerted about a “very grave” incident involving morphine.
Griffiths shelp: “If that had not been picked up as soon as it was it might have made the baby demise (sic).”
De la Poer shelp: “Could have been overweightal?”
Griffiths replied: “Yes.”
Asked what Letby’s deunbenevolentour was when she first met her about the error, Griffiths shelp: “I equitable reaccumulate the comparison becaparticipate I understand the other lady was very distraught and very disturb to the point where she was going to depart nursing.
“Letby, I leank, was disturb but not to the same extent. She seemed to acunderstandledge my decision. I leank perhaps she thought I was being a bit cut offe.”
Part of the action set up was for Letby to undergo more training on infusion calculations with the train enhugement nurse Yvonne Farmer before she could labor with administerled medications aget, but that was not finishd until September 2013, the inquiry heard.
Ricdifficult Baker KC, recurrenting some of the families of Letby’s victims, shelp: “One make clearation of what happened is that Lucy Letby went over your head, protested about your decision and you were overruled.
“If that is the conclusion achieveed, would you with the profit of hindsight think about that as very deceptive behaviour on the part of Letby?”
Griffiths replied: “I presume it shows a very overself-promised nurse, becaparticipate part of a nursing journey is to lget from any misconsents potentiassociate … I did leank that was inappropriate and I consent it was quite deceptive.”
Baker shelp: “Quite magnificentiose and self-convey inant as well, isn’t it?”
Griffiths shelp: “It is, yes.”
Another dosage error by Letby was flagged up in April 2016 when she administered an antibiotic that was not prescribed and not due.
Farmer tbetter the inquiry it was “not a inmeaningful error, possibly a convey inant error” but Letby count ond it was “uneludeable”.
In her echoions on the incident, Letby wrote: “The misconsent was genuineised promptly by myself and a colleague promptly after the dose had been given, and my initial worry was for the getedty of the baby. The registrar was alerted and meadeclareives were consentn to asdeclareive that the infant was watched accordingly and that no harm had occurred.
“Although not excusable at the time, myself and my colleague were administering multiple antibiotics all due at a aenjoy time, as well as caring for our own discdisthink about-mindeds and helping youthfuler members of the team, including a novelly qualified nurse, when the unit was not staffed with ample sfinish join.
“On echoion, I experience this situation was uneludeable and attfinish was given to the best of our ability. However, understanding how the circumstances could have potentiassociate ill-impacted the process of giving antibiotics, I should have been more conscious and made an even wonderfuler effort to asdeclareive all the relevant examines were made before giving, and time should have been more prioritised more accordingly.”
Letby, 34, from Hereford, is serving 15 whole-life orders after she was convicted at Manchester crown court of killinging seven infants and trying to killing seven others, with two trys on one of her victims, between June 2015 and June 2016.
The inquiry is predicted to sit until punctual 2025, with discoverings published by postponecessitate autumn of that year.
