WEBVTT - The Countess 0:00:00.120 --> 0:00:04.479 Before we begin, please be aware this series contains discussions 0:00:04.519 --> 0:00:08.879 around infant deaths and other difficult topics. Please take care 0:00:08.960 --> 0:00:15.400 while listening. The moment my daughter was born, the doctors 0:00:15.480 --> 0:00:20.520 noticed strange markings on her skin. Within hours, someone gently 0:00:20.560 --> 0:00:28.960 explained she might have a rare genetic disorder. I remember 0:00:29.040 --> 0:00:34.120 sitting in the postpartum room, exhausted and terrified while my fragile, 0:00:34.560 --> 0:00:38.720 beautiful baby girl had dozens of wires taped to her scalp. 0:00:39.680 --> 0:00:44.000 I couldn't help her, I couldn't hold her. Like all 0:00:44.159 --> 0:00:48.120 first time parents, I had been expecting that cinematic moment, 0:00:48.800 --> 0:00:52.600 skin on skin, a warm little body settling into mine, 0:00:53.320 --> 0:00:58.120 the quiet breath of relief after months of waiting. Instead, 0:00:58.600 --> 0:01:02.080 I spent the next six month months in limbo, fearing 0:01:02.160 --> 0:01:06.160 she might never walk or talk, that she might go blind, 0:01:06.840 --> 0:01:10.319 that a tiny hidden defect in her heart might stop 0:01:10.360 --> 0:01:15.160 it altogether. When I became a mother, I knew I 0:01:15.160 --> 0:01:19.200 would sacrifice everything to help my child. But this was 0:01:19.319 --> 0:01:22.960 not a problem I could fix, and I was left 0:01:23.040 --> 0:01:28.080 with no choice but to trust. Trust the nurses lifting 0:01:28.120 --> 0:01:32.360 her from my arms, Trust the doctors who did test 0:01:32.560 --> 0:01:37.279 after test, Trust the specialist who spoke in a calm 0:01:37.400 --> 0:01:41.000 voice about a possibility that parts of her brain might 0:01:41.040 --> 0:01:46.880 be missing. Because in the Niku, trust isn't optional. It's 0:01:46.920 --> 0:01:50.480 the air you breathe. You hand over the most precious 0:01:50.520 --> 0:01:54.520 thing in your life to people you barely know, believing 0:01:54.680 --> 0:01:59.680 they will protect what you can't. That vulnerability defines the 0:01:59.680 --> 0:02:08.320 ex experience. It's overwhelming and it's necessary. And then, finally, mercifully, 0:02:08.880 --> 0:02:12.360 the doctors told us she had tested negative. That her brain, 0:02:12.639 --> 0:02:17.600 her heart, her eyes, they were just fine. I'll never 0:02:17.639 --> 0:02:22.639 forget that feeling, the world opening up again, the gratitude 0:02:22.720 --> 0:02:27.040 so heavy it almost knocked me off my feet. Most 0:02:27.160 --> 0:02:29.800 parents with a child in the nic you get that moment, 0:02:30.680 --> 0:02:34.360 But in twenty fifteen, at the Countess of Chester Hospital, 0:02:35.200 --> 0:02:54.040 some never did. The historic heart of Chester is like 0:02:54.080 --> 0:02:57.920 a time capsule, filled with everything you expect from a 0:02:58.040 --> 0:03:03.400 very old, very storied British city, cobbled streets, pubs dating 0:03:03.440 --> 0:03:07.720 back to medieval times, an imposing stone cathedral and an 0:03:07.800 --> 0:03:11.840 honest to goodness castle Tucked in one corner, all surrounded 0:03:11.880 --> 0:03:16.000 by a great, big, fortified wall. Right at the edge 0:03:16.040 --> 0:03:20.200 of Chester is the local hospital named after Princess Diana. 0:03:20.800 --> 0:03:23.080 It's called the Countess of Chester, which was one of 0:03:23.120 --> 0:03:25.679 the titles she got when she married King Charles. 0:03:29.880 --> 0:03:31.480 But the history of the site where. 0:03:31.280 --> 0:03:35.360 The hospital was built isn't, shall we say, quite as 0:03:35.480 --> 0:03:38.400 illustrious as the stuff in the old city center. 0:03:39.160 --> 0:03:42.800 The Countess of Chester originally was built on the site 0:03:43.160 --> 0:03:47.240 of a Victorian mental asylum. 0:03:48.200 --> 0:03:51.040 That's Michelle Warden. She used to work at the Countess 0:03:51.040 --> 0:03:54.200 of Chester as a neonatal nurse. She started a few 0:03:54.240 --> 0:03:56.680 years after Charles and Diana's royal visit. 0:03:57.720 --> 0:03:58.840 Speaking of which. 0:03:59.120 --> 0:04:02.600 The hospital built itself doesn't exactly live up to its 0:04:02.640 --> 0:04:07.760 regal name. It's, you know, a hospital. It looks like 0:04:07.800 --> 0:04:14.119 a hospital built in the seventies. You can probably picture it, unfussy, functional, 0:04:14.640 --> 0:04:18.000 lots of concrete. But this run of the mill building 0:04:18.160 --> 0:04:22.240 and what happened inside has for the past decade been 0:04:22.279 --> 0:04:25.000 at the center of the latest big chapter in the 0:04:25.080 --> 0:04:29.280 history of Chester. In fact, many believe that what happened 0:04:29.320 --> 0:04:31.919 here is one of the biggest things to have happened 0:04:31.960 --> 0:04:37.280 in the history of modern Britain. The country just hasn't 0:04:37.320 --> 0:04:42.520 settled on what that thing is. History is still being written. 0:04:43.640 --> 0:04:48.880 They clearly felt that she's one of Britain's most notorious. 0:04:48.200 --> 0:04:50.760 Killers what to do about a trial which, in my 0:04:50.920 --> 0:04:54.520 view is a clear mischaracter justice by a judicial system 0:04:54.960 --> 0:05:00.359 that could not manage. 0:04:59.240 --> 0:05:03.320 I'm Amanda not and from Vespucci and iHeart podcasts. This 0:05:03.640 --> 0:05:15.680 is doubt the case of Lucy Leppie episode two, The Countess. 0:05:19.320 --> 0:05:20.400 Back in twenty fifteen. 0:05:20.560 --> 0:05:23.240 When you arrive at the Countess, that's how a lot 0:05:23.240 --> 0:05:25.760 of people refer to it. By the way, the Countess, 0:05:26.200 --> 0:05:28.320 one of the first things you'll see is a short, 0:05:28.360 --> 0:05:31.839 stocky building to your left. That was the women and 0:05:31.920 --> 0:05:32.840 Children's building. 0:05:33.040 --> 0:05:38.000 I mean, the women and Children's department. Hospital was designed for, 0:05:38.160 --> 0:05:40.120 as it says, women and children. So you've got a 0:05:40.160 --> 0:05:42.840 pediatric ward, you have in the natal ward, you have 0:05:43.040 --> 0:05:44.839 all the maternity. 0:05:44.600 --> 0:05:47.920 Michelle again, she spent so many years in this building, 0:05:48.080 --> 0:05:50.839 she could probably recite the layout in her sleep. 0:05:51.000 --> 0:05:57.000 You've got fetal medicine unit, anti natal, postnatal, guynecology, you've 0:05:57.040 --> 0:06:01.840 got operating theaters, infertility. Anything to do with women and 0:06:01.960 --> 0:06:04.440 children is within that building. 0:06:05.080 --> 0:06:08.279 But a lot has changed since Michelle first started working 0:06:08.279 --> 0:06:13.599 there in many important ways, some for the better and 0:06:14.000 --> 0:06:14.919 some for the worse. 0:06:16.720 --> 0:06:21.840 It wasn't until the mid nineteen nineties, with the development 0:06:22.080 --> 0:06:25.719 of a drug which helps to develop premature baby's lungs. 0:06:26.360 --> 0:06:31.200 That really revolutionized the care of these sick and premature babies. 0:06:33.240 --> 0:06:37.000 Though new drugs helped the infants breathe easier, the same 0:06:37.240 --> 0:06:40.720 couldn't be said for the facilities. By the time Michelle 0:06:40.800 --> 0:06:44.040 retired in two thousand and seven, the women and Children's 0:06:44.080 --> 0:06:47.080 building itself was coughing and spluttering. 0:06:47.480 --> 0:06:51.520 It was a lovely unit, but it was old, and 0:06:51.880 --> 0:06:56.520 with any old building, it had its problems which were 0:06:57.080 --> 0:06:59.520 always going on. I went to work on the unit 0:06:59.520 --> 0:07:03.800 in ninety ten, eighty eight, and where and tear was 0:07:03.880 --> 0:07:07.720 beginning to show. Even back then, problems with the plumbing, 0:07:08.360 --> 0:07:12.120 the sinks and the taps sometimes not working properly. 0:07:13.240 --> 0:07:16.080 The plumbing system had recycled the Victorian pipes in the 0:07:16.120 --> 0:07:21.920 foundation from the ground's mental asylum days, sewage would back 0:07:22.040 --> 0:07:25.240 up into the sinks. It would also leak from the 0:07:25.280 --> 0:07:33.239 pipes overhead onto the incubators. This was a chronically underfunded unit, 0:07:33.880 --> 0:07:38.280 and often the maintenance crew was forced to improvise. One 0:07:38.320 --> 0:07:41.600 maintenance worker described to the Telegraph newspaper a time he 0:07:41.680 --> 0:07:44.680 and his colleagues had to pad the ceiling tiles with 0:07:44.920 --> 0:07:48.840 diaper lining. A last ditch effort to stem the flow 0:07:48.920 --> 0:07:53.800 of literal shit from the pipes overhead. There was never 0:07:54.000 --> 0:07:57.440 enough time or money to put out all the fires. 0:08:01.240 --> 0:08:04.240 By the summer of twenty fifteen, the hospital had been 0:08:04.280 --> 0:08:07.920 begging the public for help, pleading for donations. 0:08:08.240 --> 0:08:10.760 She's raising money for the Countess of Chester. Does Baby 0:08:10.760 --> 0:08:12.440 Grow a pail launched to raise. 0:08:12.280 --> 0:08:14.800 Three million pounds to build a new neo natal special 0:08:14.840 --> 0:08:16.160 Baby Kay unit to provide. 0:08:17.120 --> 0:08:20.960 Everyone threw themselves into the effort, racing rubber duckies on 0:08:21.000 --> 0:08:23.920 the River Dee, charging down the streets of Chester in 0:08:24.000 --> 0:08:28.520 Santa costumes, and gamely taking part in goofy dance videos 0:08:29.040 --> 0:08:31.360 like the one with the pediatrician in charge of the unit, 0:08:31.560 --> 0:08:34.680 doctor Stephen Breery, shaking his hips to the tune of 0:08:34.679 --> 0:08:38.480 Twist and Shout and making heart shapes with his hands, 0:08:38.559 --> 0:08:39.520 all for the cause. 0:08:40.440 --> 0:08:41.120 On behalf of. 0:08:41.040 --> 0:08:43.760 The doctors and nurses that work in Chester on the 0:08:43.840 --> 0:08:44.720 neonatal unit. 0:08:44.920 --> 0:08:46.800 That's him. Doctor Breery would. 0:08:46.720 --> 0:08:49.920 Like to express my sinceres thanks be very kind donation. 0:08:51.280 --> 0:08:55.800 Soft spoken, self effacing, Doctor Breery had that pillar of 0:08:55.840 --> 0:08:59.839 the community vibe to him. But the real poster boy 0:09:00.120 --> 0:09:05.360 the pediatric team was doctor Breery's close friend doctor Rovi Jayram. 0:09:05.720 --> 0:09:09.000 He was thin and sprightly with a shock of curly 0:09:09.080 --> 0:09:15.200 black hair. The local papers called him the TV doctor and. 0:09:15.120 --> 0:09:17.640 Doctor Rabi Jerram is with us now because we're going 0:09:17.679 --> 0:09:18.560 to talk about this a little bit. 0:09:18.559 --> 0:09:21.880 Mind j If I'm a consultant pediatrician and I've worked 0:09:21.880 --> 0:09:22.960 for the NHS all. 0:09:22.840 --> 0:09:27.800 My career, consultant is the most senior rank of doctor 0:09:27.880 --> 0:09:31.080 in the UK. You'll be hearing that word a lot 0:09:31.240 --> 0:09:35.840 in this series. Doctor Jayram was a consultant and just 0:09:35.880 --> 0:09:38.800 so we're all on the same page. NHS stands for 0:09:39.040 --> 0:09:43.319 National Health Service. It's the UK system of free healthcare 0:09:43.360 --> 0:09:47.560 for all. Making it to consultant level took a long 0:09:47.679 --> 0:09:51.440 time and a ton of work. But through all those 0:09:51.520 --> 0:09:56.040 sleep deprived years, doctor Jayram never forgot to nurture his 0:09:56.120 --> 0:10:02.280 first love, showbiz. He busked on the streets of Chester 0:10:02.440 --> 0:10:05.600 as a teen, shot his shot at the Edinburgh Fringe 0:10:05.640 --> 0:10:10.560 Festival in college, and became a mainstay of British game shows, 0:10:10.600 --> 0:10:12.960 all while coming up the ranks in medicine. 0:10:13.080 --> 0:10:14.480 This is your third appearance. 0:10:14.960 --> 0:10:18.600 It is yes, that's him on the weakest link. He 0:10:18.679 --> 0:10:19.839 actually won at one point. 0:10:19.920 --> 0:10:22.560 Anything else I indulge in the occasional karaoke. 0:10:22.760 --> 0:10:23.559 Puts your board down? 0:10:25.200 --> 0:10:25.920 What can you sing? 0:10:27.040 --> 0:10:29.080 I could do honky Tonk Women by the Rolling Stones 0:10:29.120 --> 0:10:29.679 in tribute to you. 0:10:29.760 --> 0:10:31.640 Well, I doubt whether you can, but you can try. 0:10:32.600 --> 0:10:33.360 Have you started it? 0:10:34.520 --> 0:10:39.120 I met a Jinsea barn queen in Memphis. 0:10:39.679 --> 0:10:43.200 She tried to take me upstairs. 0:10:42.480 --> 0:10:43.520 For a ride. 0:10:45.240 --> 0:10:48.320 In his downtime, Doctor Jayram played local gigs with his 0:10:48.440 --> 0:10:56.120 band The Diluted. Here they are at the Cavern, a 0:10:56.200 --> 0:10:59.480 live music spot in Liverpool where The Diluted were a 0:10:59.559 --> 0:11:00.640 regular attraction. 0:11:04.080 --> 0:11:06.200 He's actually got a good singing voice and he is 0:11:06.559 --> 0:11:10.079 very theatrical. I actually asked him why he didn't pursue 0:11:10.160 --> 0:11:13.280 a career in drama and he said, well, that's not 0:11:13.400 --> 0:11:16.920 what nice Indian boys do, is that? I mean? His 0:11:16.960 --> 0:11:20.880 father was a consultant, his brother is a very eminent 0:11:21.559 --> 0:11:24.079 consultant ophthalmologist in London. 0:11:24.520 --> 0:11:27.400 But doctor jerm found a way to make his medical 0:11:27.440 --> 0:11:31.040 career and his rockstar ambitions work for him. In the 0:11:31.080 --> 0:11:33.960 summer of twenty fifteen, he was co starring in a 0:11:34.000 --> 0:11:38.000 reality TV show called Born Naughty, where he and a 0:11:38.000 --> 0:11:42.280 fellow doctor met parents of badly behaved children and decided 0:11:42.320 --> 0:11:46.440 if a medical diagnosis was the answer to their problems. 0:11:45.920 --> 0:11:47.880 As a pediatrician and a GP. 0:11:48.440 --> 0:11:51.240 Dr Ravi and Dr Dawn often meet badly. 0:11:50.960 --> 0:11:54.920 Behave kids, but now they must crack some real hard nuts. 0:11:55.160 --> 0:11:58.160 He spent the early part of that summer criss crossing 0:11:58.200 --> 0:12:01.559 the country doing promo or his reality show, as well 0:12:01.600 --> 0:12:06.200 as other media work. He seemed to be everywhere except 0:12:06.360 --> 0:12:11.479 perhaps the understaffed neonatal unit at the Countess of Chester Hospital. 0:12:13.679 --> 0:12:15.040 But just as the. 0:12:15.000 --> 0:12:19.240 Future is looking bright, something terrible starts unfolding in the 0:12:19.280 --> 0:12:23.120 neonatal unit. It won't be long before the unit is 0:12:23.160 --> 0:12:27.240 demanding all of doctor jay Rum's attention. There will be 0:12:27.320 --> 0:12:45.120 little time left for show business. In the UK, not 0:12:45.360 --> 0:12:49.360 every nick you is the same. Neonatal units are graded 0:12:49.720 --> 0:12:53.040 level one through three, depending on what level of care 0:12:53.120 --> 0:12:57.040 they are equipped to provide. Jenny Harris, who spent years 0:12:57.080 --> 0:13:00.000 as a neonatal nurse in the NHS, helped me out 0:13:00.080 --> 0:13:02.440 understand what those levels actually mean. 0:13:02.760 --> 0:13:05.560 If your hospital has a Level one nionatal unit, that 0:13:05.720 --> 0:13:09.120 means that you can just care for babies that just 0:13:09.200 --> 0:13:13.800 need feeding and growing, maybe a little help with respiratory support, 0:13:13.840 --> 0:13:18.600 but only like minor respiratory support like oxygen. 0:13:19.920 --> 0:13:21.840 Then you have your level two unit. 0:13:22.240 --> 0:13:25.200 They can also take high dependency babies, so these are 0:13:25.240 --> 0:13:30.400 babies that need safe seapap, may need fluids, premature babies 0:13:30.440 --> 0:13:34.080 up to a certain gestation. And then your level three 0:13:34.240 --> 0:13:37.559 unit is the unit that does everything so special care, 0:13:37.640 --> 0:13:41.959 high dependency, all intensive care, babies, whatever they may need. 0:13:42.520 --> 0:13:44.920 And what they do is say there is a baby 0:13:44.960 --> 0:13:46.800 and a Level one unit that needs to go to 0:13:46.840 --> 0:13:50.760 a Level three, then in the transport team would go 0:13:50.840 --> 0:13:54.000 to that baby, stabilize the baby, and take it to 0:13:54.080 --> 0:13:57.760 the hospital that's more equipped to care for that baby. 0:13:58.559 --> 0:14:02.600 Jenny worked on the transfer team. She spent years moving 0:14:02.720 --> 0:14:06.800 tiny patients from one hospital to another, from one level 0:14:06.800 --> 0:14:10.520 of care to the next. The Countess of Chester was 0:14:10.520 --> 0:14:11.600 a Level two unit. 0:14:12.000 --> 0:14:15.080 My favorite was going to the Level ones and the 0:14:15.160 --> 0:14:20.320 Level twos because they were so cozy, quiet. They're all 0:14:20.760 --> 0:14:24.880 decorated nice, and you know, got pictures on the walls 0:14:24.960 --> 0:14:29.720 and selling knitted stuff and a little trolley, like it's 0:14:29.840 --> 0:14:33.160 just so lovely. You just go in and it's just, yeah, 0:14:33.200 --> 0:14:34.920 it just seems more homely. 0:14:38.080 --> 0:14:43.080 For the parents. The nick Yu is both terrifying and miraculous. 0:14:44.440 --> 0:14:48.440 It's where the smallest lives fight their biggest battles. A 0:14:48.520 --> 0:14:54.360 place of constant fear, yes, but also of hope. The 0:14:54.440 --> 0:14:58.000 Unit of the Countess in summer twenty fifteen, like many 0:14:58.040 --> 0:15:02.400 across the UK, is worn and cozy. It cares for 0:15:02.480 --> 0:15:08.360 premature babies, babies who struggle to breathe, to feed, to grow, 0:15:09.320 --> 0:15:13.040 and it isn't known for high death rates. From twenty 0:15:13.120 --> 0:15:17.280 eleven to twenty fourteen, two or three babies died there 0:15:17.400 --> 0:15:28.560 each year. On paper it was unremarkable. It's early June 0:15:29.120 --> 0:15:35.080 and a set of twins has just been born. They're premature, tiny, 0:15:35.640 --> 0:15:40.480 but breathing. Their mother has a rare autoimmune condition which 0:15:40.520 --> 0:15:44.680 made her pregnancy risky. At seven months, her twins are 0:15:44.720 --> 0:15:48.440 born by sea section and whisked away to the neonatal unit. 0:15:49.160 --> 0:15:52.240 Here's Michelle again, the nurse that worked at the Countess. 0:15:53.080 --> 0:15:55.200 They were supposed to be born in London and the 0:15:55.320 --> 0:16:00.640 mum had antiphosphilipid syndrome, so they delivered her inesca. 0:16:01.280 --> 0:16:05.720 The twins are placed in adjoining cots, tubes for feeding, 0:16:06.560 --> 0:16:11.480 wires for monitoring in place of their mother's heartbeat, They 0:16:11.560 --> 0:16:19.720 now hear something else. Monitors footsteps hushed voices, the unfamiliar 0:16:19.760 --> 0:16:26.520 rhythms of the neonatal unit take over. Unlike many American hospitals, 0:16:26.840 --> 0:16:31.000 where parents can stay around the clock, UK neonatal units 0:16:31.000 --> 0:16:35.800 are often more nurse led, parents come and go, care 0:16:35.920 --> 0:16:40.160 continues through the night, and like so many parents in 0:16:40.200 --> 0:16:44.440 a neonatal ward, the twins' parents were most likely offered 0:16:44.560 --> 0:16:49.880 gentle reassurance, the kind meant to steady you when everything 0:16:50.040 --> 0:16:51.119 feels uncertain. 0:16:52.480 --> 0:16:55.120 They just need a little more time. They're in the 0:16:55.160 --> 0:16:55.840 best place. 0:16:57.480 --> 0:17:00.280 I remember hearing a version of that myself when my 0:17:00.360 --> 0:17:04.160 daughter was in hospital. We have our best people on it. 0:17:04.680 --> 0:17:13.040 You're doing great. No promises, no guarantees, just something soft 0:17:13.160 --> 0:17:18.320 enough to hold onto. But when nothing feels certain, you 0:17:18.480 --> 0:17:23.359 hold onto hope and trust. But for the parents of 0:17:23.400 --> 0:17:29.040 these twins, that trust became heavy the moment the alarm sounded. 0:17:35.000 --> 0:17:40.520 Something is wrong. Their baby boy's condition has deteriorated. Suddenly, 0:17:48.880 --> 0:17:52.720 hours later, they're holding him, but not in the way 0:17:52.760 --> 0:17:57.280 they had hoped. In a later victim impact statement, his 0:17:57.440 --> 0:18:01.639 parents would describe how quote, we never got to hold 0:18:01.680 --> 0:18:07.240 our little boy while he was alive. Doctor Jayram was 0:18:07.280 --> 0:18:11.280 there that night. There was no clear answer he could 0:18:11.280 --> 0:18:16.600 give the parents. Years later, during his testimony during Lucy 0:18:16.640 --> 0:18:20.719 let Be's trial, doctor Jayram would recall the awful conversation 0:18:20.840 --> 0:18:24.199 he had to have with the parents that night. It 0:18:24.280 --> 0:18:27.760 was a difficult situation, he'd say, when the first thing 0:18:27.840 --> 0:18:30.320 you have to tell a family is that number one, 0:18:30.920 --> 0:18:34.600 I'm not sure what's going on, and number two, I 0:18:34.680 --> 0:18:37.080 don't think we're going to be able to bring him back. 0:18:39.320 --> 0:18:42.920 With their daughters still in intensive care, the parents were 0:18:42.960 --> 0:18:48.480 forced to do the impossible to grieve one child while 0:18:48.560 --> 0:18:49.359 hoping for. 0:18:49.280 --> 0:18:51.719 The other baby. 0:18:51.720 --> 0:18:55.720 A's nurse, Lucy let Be makes them a memory box, 0:18:56.400 --> 0:19:02.240 a lock of hair, a footprint, a tiny knitted Years later, 0:19:02.720 --> 0:19:06.080 in a court of law, these mementos would take on 0:19:06.280 --> 0:19:16.480 a very different meaning. One day later, the alarm sounds again. 0:19:17.560 --> 0:19:22.600 This time their daughter, the surviving twin, has collapsed. Thankfully, 0:19:23.080 --> 0:19:29.479 the doctors intervene in time. Neonatal medicine is a world 0:19:29.720 --> 0:19:34.680 built on watchfulness. Doctors and nurses are used to things 0:19:34.840 --> 0:19:39.679 changing suddenly, to alarms, to emergencies, to living in a 0:19:39.760 --> 0:19:47.160 constant state of readiness. Because these babies are fragile, unbelievably fragile. 0:19:48.200 --> 0:19:49.200 Here's Jenny again. 0:19:49.440 --> 0:19:52.960 There's so many things that can go wrong with preterm babies. 0:19:53.000 --> 0:19:54.360 This so sensitive. 0:19:54.920 --> 0:19:57.879 Even change in their nappy can cause them to have 0:19:57.920 --> 0:20:01.640 a bleed on their brain. People just don't realize how 0:20:01.800 --> 0:20:05.840 sensitive these babies are. That's very rare, but it can happen. 0:20:08.000 --> 0:20:08.800 Most days. 0:20:08.920 --> 0:20:12.920 They managed to pull babies back from the edge, and 0:20:12.960 --> 0:20:16.000 then there are the days that stay with them forever. 0:20:18.000 --> 0:20:21.000 What happened during those forty eight hours left the nurses 0:20:21.040 --> 0:20:25.359 and doctors on the unit in shock. Of course, these 0:20:25.400 --> 0:20:28.880 twins had names, but because the courts ruled that none 0:20:28.920 --> 0:20:31.040 of the names of the babies in this case could 0:20:31.040 --> 0:20:34.200 ever be made public, they came to be known as 0:20:34.240 --> 0:20:40.200 Baby A and Baby B. One day, the UK justice 0:20:40.200 --> 0:20:44.800 system would officially recognize Baby A as the first known 0:20:44.960 --> 0:20:47.560 victim of a serial killer nurse. 0:20:57.240 --> 0:20:59.520 Now, I want to be careful here. 0:21:00.040 --> 0:21:02.880 It's hard for me to truly grasp what these parents 0:21:02.920 --> 0:21:12.000 lived through, although I myself have experienced what it's like 0:21:12.080 --> 0:21:15.159 to have a newborn in the hospital. To then be 0:21:15.359 --> 0:21:18.760 told that the person you trusted with your baby's life 0:21:19.480 --> 0:21:23.560 may have been the one who took it. It's unimaginable 0:21:24.800 --> 0:21:29.720 and yet, regardless of where the truth ultimately lies, this 0:21:30.160 --> 0:21:35.080 is the reality these parents have been living inside. When 0:21:35.080 --> 0:21:38.040 I spoke to doctor Phil Hammond, you may remember from 0:21:38.040 --> 0:21:42.520 episode one we discussed the power of grief, how it 0:21:42.680 --> 0:21:46.440 forces one to search for answers and for the parents. 0:21:46.480 --> 0:21:48.160 In this case, the. 0:21:48.200 --> 0:21:51.439 Parents' supportive by the laws is still absolutely convinced of 0:21:51.520 --> 0:21:54.880 her guilt because they've spent so much of their life 0:21:54.920 --> 0:21:57.280 invested in this. Imagine the emotion of the verdict to 0:21:57.400 --> 0:21:58.280 all that stuff. 0:22:04.080 --> 0:22:10.240 Tragically, four days after baby B collapses, Baby C dies 0:22:11.080 --> 0:22:15.359 a boy, and eight days after that a baby girl 0:22:16.280 --> 0:22:25.040 Baby D. Three deaths and one unexplained collapse in two weeks. 0:22:25.680 --> 0:22:28.960 Even on a unit where the babies are compromised, this 0:22:29.320 --> 0:22:33.720 was unusual. The staff tended to see three baby deaths 0:22:33.920 --> 0:22:34.440 a year. 0:22:35.400 --> 0:22:38.080 Three and two weeks was a crisis. 0:22:39.119 --> 0:22:41.199 By the end of that summer, the NIKU at the 0:22:41.200 --> 0:22:49.119 Countess would be forever changed. There were more collapses, more funerals. 0:22:49.160 --> 0:22:54.760 Parents brought in balloons for milestones, only to leave with condolences, 0:22:54.800 --> 0:22:59.200 and quietly a question began to swirl amongst the staff, 0:23:00.440 --> 0:23:02.000 why is this happening? 0:23:03.160 --> 0:23:07.399 So I remember within the hospital, within the our team 0:23:07.800 --> 0:23:11.440 at handover, it was a regular topic of conversation. 0:23:12.280 --> 0:23:15.480 These are the words of doctor Rachel Lamby read by 0:23:15.520 --> 0:23:19.000 an actor. They are from transcripts of her testifying at 0:23:19.040 --> 0:23:22.160 a public inquiry which was set up right after Lucy 0:23:22.240 --> 0:23:27.240 Leppi's conviction. This inquiry had a very specific mandate to 0:23:27.320 --> 0:23:30.439 figure out if let Be the serial killer could have 0:23:30.560 --> 0:23:35.520 been stopped sooner. Back in twenty fifteen, doctor Lamby was 0:23:35.560 --> 0:23:39.359 still a doctor in training. In England, doctors in training 0:23:39.440 --> 0:23:45.159 are referred to as registrars or junior doctors. Doctor Lambey 0:23:45.320 --> 0:23:47.440 was one of the first people on the scene when 0:23:47.480 --> 0:23:50.639 Baby A's alarm went off. She was there the next 0:23:50.720 --> 0:23:55.320 night too, when his twin sister, Baby Be collapsed. By 0:23:55.320 --> 0:23:59.080 the time Baby C and D die, everyone is on 0:23:59.280 --> 0:24:02.960 high alert. Here's an actor again reading a section of 0:24:03.000 --> 0:24:05.680 testimony from doctor Lamby during the inquiry. 0:24:06.240 --> 0:24:08.960 I remember, on more than one occasion almost a heart 0:24:09.040 --> 0:24:12.080 sink feeling of Oh gosh, what's going to happen today? 0:24:12.760 --> 0:24:16.119 In this moment of crisis, a fissure begins to form. 0:24:16.160 --> 0:24:20.240 Amongst the staff. On one side are the registrars and 0:24:20.280 --> 0:24:23.959 the nurses. They're looking to the senior doctors in charge, 0:24:24.320 --> 0:24:26.200 the consultants for answers. 0:24:27.280 --> 0:24:27.960 On the other. 0:24:27.920 --> 0:24:32.120 Side are the consultants. There are seven of them together. 0:24:32.440 --> 0:24:35.520 They're responsible for all of the children who pass through 0:24:35.560 --> 0:24:38.879 the building, from the most premature of babies to the 0:24:38.960 --> 0:24:42.960 seventeen year old with a broken leg. Doctor jayram leads 0:24:43.000 --> 0:24:47.280 the pediatric department and doctor Breary the neonatal unit. 0:24:48.600 --> 0:24:50.159 The consultants don't have. 0:24:50.040 --> 0:24:53.840 Any answers for the sudden spate of baby deaths, but 0:24:53.920 --> 0:24:56.320 they also don't want the rest of the staff to 0:24:56.400 --> 0:24:58.640 think they don't have this under control. 0:25:02.280 --> 0:25:05.720 Dear aw Rachel Lambi came to see me this morning. 0:25:06.320 --> 0:25:09.320 This is how one of the consultants, doctor John Gibbs, 0:25:09.600 --> 0:25:12.600 begins an email to the six others the day after 0:25:12.680 --> 0:25:16.200 Babyde's death. Here's an actor reading what he wrote. 0:25:16.640 --> 0:25:20.760 The registrars are very concerned about the recent neonatal deaths 0:25:20.880 --> 0:25:26.359 and collapses. Rachel also said that all the neonatal nurses 0:25:26.359 --> 0:25:30.080 are very worried. They feel we ought to be doing something. 0:25:30.560 --> 0:25:34.560 Although I've mentioned we are looking into this, I'm not 0:25:34.760 --> 0:25:37.960 sure exactly how this is being done. I think a 0:25:38.040 --> 0:25:41.240 meeting would be useful, even if we have no answers. 0:25:41.960 --> 0:25:44.679 In an effort to put the others at ease, Doctor 0:25:44.720 --> 0:25:47.320 Breerry says that he and the head of the neonatal 0:25:47.400 --> 0:25:50.439 nursing team have carefully gone over the details of the 0:25:50.480 --> 0:25:54.480 three recent deaths to see if there's anything connecting them. 0:25:54.800 --> 0:25:59.320 But as he would tell the BBC years later, there. 0:25:59.200 --> 0:26:05.520 Was nothing in common that we could pin this three 0:26:05.640 --> 0:26:07.720 deaths on. 0:26:09.480 --> 0:26:13.520 Well, maybe there is one thing. Doctor Breery has gone 0:26:13.560 --> 0:26:17.240 through the work schedule for the nurses and notices one 0:26:17.359 --> 0:26:21.080 nurse who has been on duty when all three babies died. 0:26:22.359 --> 0:26:27.040 Stuffing analysis did identify that lucy let Be was on 0:26:27.200 --> 0:26:29.520 shift for those three episodes. 0:26:30.520 --> 0:26:35.199 A pattern starts to emerge. In August, a fourth baby dies, 0:26:35.720 --> 0:26:39.600 lucy let Be was his nurse. In September, lucy let 0:26:39.600 --> 0:26:42.320 Be is on duty when one of two babies die. 0:26:42.960 --> 0:26:47.320 In October, another baby, lucy let Be is on duty again, 0:26:48.040 --> 0:26:52.520 in December another and again lucy let Be was there 0:26:53.520 --> 0:26:56.720 eight deaths by the end of the year, lucy let 0:26:56.720 --> 0:27:01.200 Be is present for seven. For or Breery, what could 0:27:01.200 --> 0:27:05.840 be dismissed at first as mere correlation is hardening into 0:27:05.840 --> 0:27:08.159 a strong basis for suspicion. 0:27:12.440 --> 0:27:17.879 I'd like to speak to the families. Sorry, Sorry for 0:27:17.960 --> 0:27:21.080 my part in not being able to protect your babies. 0:27:21.880 --> 0:27:25.640 I tried my best, and I acknowledged that at times 0:27:25.960 --> 0:27:27.320 my best was not good enough. 0:27:28.160 --> 0:27:32.000 That's an actor reading from transcripts of doctor Breery testifying 0:27:32.040 --> 0:27:34.280 at the inquiry about a year and a half ago. 0:27:35.119 --> 0:27:38.800 He looks much older now, older perhaps than you might 0:27:38.840 --> 0:27:42.440 expect the rosy cheeked doctor in the light hearted fundraising 0:27:42.560 --> 0:27:46.280 videos to be. The toll of the last ten years 0:27:46.680 --> 0:27:51.600 is clearly visible in his appearance. Doctor Breery was the 0:27:51.640 --> 0:27:55.080 first of the consultants to notice a correlation between Lucy 0:27:55.160 --> 0:27:59.440 let Bey's workshifts and the deaths of babies. The way 0:27:59.480 --> 0:28:02.399 he says he remembers it, it had actually been the 0:28:02.440 --> 0:28:06.639 head of the neonatal Nurses, Arian Powell, who had pointed 0:28:06.640 --> 0:28:10.040 the correlation out to him, and that his instinctive reaction 0:28:10.200 --> 0:28:14.280