Inevitably, right now everyone from the medical professions through to the media is responding to the tragic case with demands that ‘something must be done’ and that this ‘can never happen again’.
They are familiar refrains following a disaster or tragic loss of life enabled by the failures of institutions to act appropriately.
But such is the gravity of this tragedy that the real challenge is whether a meaningful and long-lasting legacy can be drawn from this shocking case that actually ensures that organisational governance is established and executed in such a way that malevolent practitioners are identified and stopped quickly.
At the end of August, Health and Social Care Secretary Steve Barclay announced that the inquiry into the circumstances around crimes committed by Lucy Letby will become statutory after listening to the views of families of the victims. The move will give the inquiry legal powers which include compelling witnesses to give evidence under oath.
The inquiry will look at the circumstances surrounding the actions of former neonatal nurse Lucy Letby.
Acknowledging that statutory inquiries traditionally take longer to conclude, the government stressed that moving to a statutory footing will mean the inquiry will have legal powers to compel witnesses, including former and current staff of the Countess of Chester Hospital Trust, to give evidence. It will also mean that evidence must be heard in public, unless the inquiry chair decides otherwise.
Inevitably, there will also be discussions within the NHS as to why lessons have not been learnt from previous instances when healthcare practitioners killed patients, such as the infants murdered by Beverley Allitt in 1991, and serial killer Harold Shipman, who may have been responsible for the deaths of as many as 250 predominantly elderly patients.
In the aftermath, The Shipman Inquiry took two years to complete, such was the extent of his actions.
There have been further reports too: The Kennedy Report in Bristol and the Francis Report into the failings at Mid Staffs, which recommended improvements for raising clinical concerns. Report author Robert Francis also shared his views on whistle-blowing to Times Radio.
In 2022, the damning Kirkup Report, which found dozens of babies died or were left brain damaged by poor care within maternity services at East Kent Hospitals, included a midwife saying: “the deaths of some babies could’ve been prevented had there not been a bullying culture.”
The report found that the deaths of 45 babies at the trust could have been avoided if nationally recognised standards of care had been provided and an ITV Meridian investigation found there were multiple formal cases of bullying and harassment submitted to the Trust, with many more unreported.
Figures obtained by ITV Meridian through a Freedom of Information (FOI) request found there had been eight formal cases of bullying and harassment among maternity staff at the William Harvey Hospital in Ashford and the Queen Elizabeth the Queen Mother Hospital in Margate since 2009.
Another interesting point is the role of unconscious bias in Lucy Letby being allowed to continue working despite growing and vociferous concerns. Letby is a young, white, blonde woman with something of a girl next door look. Could that have been a factor in why the increasingly alarming coincidences mounting up about her presence when unusual and sometimes fatal incidents occurred was not believed, despite concerns being raised, and she was overlooked?
Does a murderer need to ‘look like a murderer’ to be investigated properly?
Senior doctors had warned for months that Letby was the only staff member present during the sudden collapses and deaths of a number of premature babies on the Countess of Chester hospital’s neonatal unit.
Yet she was not removed from the ward until June 2016, almost a year after senior male doctors first alerted a hospital executive to a potential link. Far from suspending Letby immediately while the validity of the claims was examined, the hospital management ordered these doctors to apologise to Letby after their internal reviews.
Such concerning news raises the spectre of whether the findings of previous inquiries have had any resonance within the health industry.
Yet the questions the latest inquiry will be tasked with answering go far beyond healthcare. This year alone, both the mechanical failure which doomed the submarine viewing the Titanic and the debacle surrounding the Spanish FA and the women’s football team can be traced back to whistle-blowers not being listened to when they raised their concerns.
In fact, the complainant over the submarine was fired and many of the Spanish players who complained were dropped and did not take part in Spain’s World Cup triumph
Which begs the question, did any of these NHS-specific cases influence the framework for raising concerns and whistle-blowing in other sectors? It would seem not.
Despite the usual assurances, will this one? And will it last?
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