The conviction of Lucy Letby provides a judicial ending – any appeals notwithstanding – to this awful and extraordinary case and a formal way of explaining what happened in the neonatal unit of the Countess of Chester Hospital between June 2015 and June 2016. Letby killed seven babies and attempted to kill six others. Her name will now be linked with other so-called British “Angels of Death”, such as Colin Norris, Benjamin Geen, Beverley Allitt, and also with Charles Cullen – more than likely America’s most prolific serial killer, rather than a “good nurse”.
However, this judicial ending still leaves unanswered a number of other questions – most obviously: why did Letby do it, and how could she go undetected on her killing spree for nearly a year? This last question is easier to answer than the first.
In researching nurses who had been convicted of murder within a hospital setting in Europe and North America – a sample that included 16 nurses convicted between 1977 and 2009 – for a paper for the Journal of Investigative Psychology and Offender Profiling in 2014, it became clear that they shared a number of common features, or personal attributes which, in my published work, were described as “red flags”.
The five most common of these red flags were: higher incidences of death on his/her shift; has a history of mental illness, or depression; makes colleagues anxious; is found to be in possession of legal and/or illegal drugs at home or in their hospital locker; and, appears to have a personality disorder.
By far the most common of these red flags was a higher incidence of death on the nurse’s shift, although this in itself was a problematic feature and had to be interpreted with care. Hospitals are places where people go because they are sick, and sometimes close to death. It has to be expected that some will die and so spikes in the number of deaths might simply be a random occurrence and does not necessarily imply that a serial killer is working on a ward, or within a specific unit.
Nor are the statistical analyses and the conclusions that are drawn from them to demonstrate a nurse’s “guilt” always reliable. Law and statistics – specifically those statistics related to an individual’s attendance and a number of deaths – might both speak the same language, but they have very different dialects. Was there really an empirical association between specific actions and specific outcomes on the ward?
Attendance data, for example, was central to the conviction of the Dutch nurse Lucia de Berk, who had been found guilty in 2003 of killing seven patients and attempting to murder three others. However, de Berk was exonerated in 2010 when academic research used by her appeal drew attention to the tricky nature of using attendance data on its own, without any medical evidence, to demonstrate her guilt. Attendance data needed to be used in conjunction with other pieces of evidence – such as those suggested by the remaining red flags – and, in relation to Norris, for example, this seems to be the basis of his ongoing appeals, as he, too, was convicted largely on attendance data.
So, attendance data alone did not set alarm bells ringing in Chester at first and, above all, the reason why Letby was able to evade detection for so long was a seeming absence of other red flags. She didn’t make her colleagues worried or anxious, but appeared to be well-integrated into the professional and social life of the unit and the hospital. She wasn’t found to be in possession of drugs, and nor did she display, as Allitt had done, evidence of having an underlying personality disorder which, in her case, was Munchausen syndrome by proxy (now usually described as “Factitious disorder imposed on another”). Nor did she have less common, but still noticeable red flags – such as being fascinated by serial killers. In other words, Letby hid in plain sight and presented as competent, caring, ordinary and simply as unlucky. There was no “smoking gun” in this case – no one ever saw her inject a baby with air, for example – but instead it was a compelling compendium of circ*mstantial evidence that eventually left the jury convinced of Letby’s guilt.
The motives of nurses who kill in hospital settings are notoriously difficult to establish. Some want to claim that they were exercising “mercy” when managing a very sick patient; although often when this is interrogated more fully, the patient was easily capable of recovering. Others simply seem to have been ridding the ward or unit – and also themselves – with demanding patients and therefore not only freeing up beds, but also their time.
A small number also had a “hero complex”. This means that they liked the attention that came with managing complex cases and, even if a number of their patients died, they were still seen as heroic for attempting to treat and care for them – perhaps even more so if the outcome was that patient’s death. These categories are not in themselves mutually exclusive and several of the nurses who murdered that I studied displayed evidence of having more than one motivation.
Letby pleaded not guilty and so it is impossible to say definitively what might have motivated her to kill, rather than to “do no harm”. She claimed that she hadn’t killed and harmed people in her care, rather than offering explanations for what she had done in mitigation. However, my sense of what she said at her trial, and how she behaved within the court, is that she liked to keep control of herself and those who surrounded her. She’s good at her image management and her presentation of self and therefore also how she expects other people will react to her. Above all, she wants to be respected.
This seems to me to be about her sense of entitlement – there’s a whiff of narcissism here too – and an expectation and exercise of power. That’s a recurring theme with many of the serial killers that I have worked with. They like power and control and deciding to take another person’s life is, of course, the ultimate way of expressing power; a power that is often missing in other aspects of their life.
A rarely asked question in all of this is: does the killer have a motivation to kill prior to choosing their profession, or does it develop after they start to work and when they realise that they can commit murder but remain undetected? After all, specific occupations seem to dominate those chosen by serial killers: healthcare and driving occupations (such as delivery workers) most obviously.
Our most prolific serial killer was Harold Shipman, a trusted, local GP working in a singleton practice, with little managerial oversight to curb his murderous behaviour. He, too, hid in plain sight until he forged the will of his last victim – and that victim’s daughter, who worked as a solicitor, challenged what had happened. But nurses and doctors have access to lethal drugs and to people who are vulnerable – especially the very young, or the very elderly – and their deaths are all too often simply seen to be a consequence of their age, or structural healthcare issues.
From those serial killers who have talked about why they kill (in itself, relatively rare), it’s obvious that they have already developed a desire to kill other people and then chose a profession that allowed them to do so. Take Robert Black and Peter Sutcliffe, for example – the latter who became a lorry driver knowing that there would be little managerial oversight of him, and that driving about Yorkshire would give him access to the people and places that other jobs would not have facilitated. As a delivery driver, Scottish serial killer Black knew road networks just as well as any satnav, and therefore also where he might abduct his victims and then discard their bodies with little chance of their being discovered. (He was convicted of the kidnap, rape and murder of four girls aged between five and 11 in the 1990s).
In all of this deeply sad and depressing story there’s hope, too. Don’t get scared. Look again at the numbers of nurses that I uncovered in my research across the world: just 16 in more than 30 years. This phenomenon is very rare and it’s clear that the vast majority of nurses want to help, not to harm.
I know this only too well as just a few weeks after Letby went on trial, my grandson Ronan was born more than two months prematurely. I got to know all about neonatal units, and watched on helplessly as Ronan, his tiny body almost entirely covered in tubes, breathed in and out fighting for his life. The nurses who worked in that neonatal unit – all women, and I actually did not encounter a male healthcare professional there – exuded knowledge, care and a professionalism that was quite simply superhuman. They really were “angels”.
I like to think about those nurses, rather than Letby, and I am only sorry that she has prevented other parents and grandparents from excitedly discussing and fussing over their own child or grandchild. Ronan, I am delighted to report, is in rude health, thanks to the professionalism of the staff who work in that hospital.
As for Letby, we might never know why she started killing, but the chances are that she did so because her underlying narcissism, and sense of entitlement, drove her behaviour so that she was always manipulating ways to be the centre of attention, even if that involved murder.
That narcissism likely existed long before June 2015. She is an outlier – a nurse who killed in plain sight – but who was also well-liked in the unit, making it all the more difficult to have spotted what was actually happening in these cases. However, the fact that she is an outlier should also give us comfort. Nurses who kill are few and far between and someone like Letby is even more unusual within that rare and small sample of Angels of Death.
‘Murder at Home: how our safest space is where we are most in danger’, by David Wilson, is out now (£22, Sphere). His paper ‘In Search of the Angels of Death: Conceptualising the Contemporary Nurse Healthcare Serial Killer’, co-written with Elizabeth Yardley, was published in the Journal of Investigative Psychology and Offender Profiling
