A Lucy Letby inquiry must answer this: why was she seen as a victim, not a killer? | Gaby Hinsliff

Grief can be an intimate thing beyond words.

To be with parents immediately after the loss of a child is to see them at their most vulnerable moment; broken, and undone. But the families trusted Lucy Letby, the intensive care nurse who seemed so dedicated to taking care of their ailing children, to be with them through the worst of it. She sobbed over the unsuspecting parents of the infants she had secretly murdered in hospital beds, helped them keep hands and feet as mementos or washed a tiny dead body. soul for the last time. Sometimes, months later, she rummages through their Facebook accounts as if coveting more.

One mother, whose son was four days old when Letby killed him, wrote in her victim impact affidavit that it felt like a horror story to know that the killer had been actively watching her grief. family. But Letby herself was not present to hear those words. After gnawing on her parents’ suffering, she denied even greater satisfaction from seeing that justice had finally caught her, refusing to appear in court for sentencing. Instead, she received word that she would die in prison privately, in her own cell.

Nor did she give any answers to the families as to why she killed and maimed their children, seemingly with such randomness that no one was close to her. noticed something seriously wrong. “The job sucks but… I just won £135 at the Grand National!!” She texted a friend, hours after attempting to murder the twins, adding a happy pony emoji. The closest thing to a confession is a series of vague notes found by the police, in which she wrote that she killed the children because she was not “good enough” and felt she would never be able to have a family of her own. By murdering other women’s children, is she trying in some way to deprive them of what she feels she herself cannot have? Or is she simply addicted to the attention, the drama, the intense emotions that surge in the neonatal ward when a baby suddenly collapses? As the judge noted, only Letby really knows why she did it. But the more pressing question facing the public inquiry is how she got away with it for so long.

Time and again, official investigations into NHS disasters identify a history of lone whistleblowers repeatedly trying but giving no warning, while management frantically tries to to avoid a scandal. At first glance, the Countess of Chester’s response to the puzzling series of deaths in the hospital’s neonatology department seems to fit that frighteningly familiar pattern. Two pediatricians, Stephen Brearey and Ravi Jayaram, heroically tried to warn that the hospital ward might have a killer in the middle, but hospital executives apparently didn’t believe it. However, trying to explain the Letby case by plunging it into an old, familiar trench risks falling into the same deadly trap that the trust appears to have done. What matters in this case is the way in which it Are not fits the conventional pattern that trusts have learned to look for, and even confounds it at times.

This is not the old tale of doctors lining up around an incompetent colleague, or some divine consultant escaping scrutiny because no subordinates are allowed to question their methods. the law of that great man. If so, the opposite: a young nurse, when senior doctors identified her as the common cause of a series of sudden infant deaths and prompted an investigation, reacted by white accused them of bullying her. Incredibly, the hospital’s subsequent complaint investigation not only concluded that there was no basis to involve the police, but also accused the doctors of making Letby feel “isolated and vulnerable.” hurt” by voicing doubts. Breathey and Jayaram are said to have been advised to write embarrassing letters of apology to a woman we know to be the killer.

If Letby evades detection for so long in part because she doesn’t look like most people’s idea of ​​a serial killer – so “beige” and “vanilla”, as one detective did. says, with her Zumba classes and holidays in Ibiza and bedroom decorated with soft toys – perhaps equally important is her do looks like many people’s idea of ​​a victim.

The story she tells about a young woman being shoved and picked up is certainly common enough, not just in the NHS, to sound convincing on the surface. At the time, hospitals were encouraged to take workplace bullying seriously, with investigations into previous scandals identifying it as an exacerbating factor. And poor care is a much more common cause of hospital deaths than serial killers.

What the investigation must uncover, however, is why it seems so much easier for the hospital to trust poor Lucy, the fictional victim of the doctors said to be looking for a scapegoat, than in the rare situation. horrifying but terrible given by their consultants. Did they see what they wanted to see, avoiding a police investigation that spooked parents and potentially ruined the trust’s reputation? Or do they simply see what they hope see, a cautionary tale for anyone inclined to interpret any set of facts through the prism of their own fixed point of view?

Given what the trial found, families have the right to demand an investigation presided over by a judge capable of persuading witnesses to testify, not the easier-to-understand version that ministers put forward. initial. But equally important is that it is led by someone who is open-minded, knowledgeable but not clouded by past experience or expectations. For the families that have suffered so much at the hands of Letby, nothing could have been more.

• Gaby Hinsliff is Guardian columnist

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