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paediatrician steve breary asked the duty manager to replace her, though the manager refused. letby went to work and a baby unexpectedly collapsed. in september, the royal college of paediatrics and child health was asked to carry out a review of the neonatal unit. it urged the trust to investigate each death individually — this didn't happen. around this time, lucy letby launched a grievance against the paediatricians that had expressed concern about her ? the internal process concluded that she had been discriminated against and victimised by the doctors on the unit. with the paediatricians still wanting a police investigation, in january 2017 an extraordinary board meeting was held. the trust apologised to letby and decided she should return to the neonatal unit. consultants continued to pressure the trust to go to the police and they finally did so in may 2017. by the time letby was arrested in july 2018,

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