Lucy Letby inquiry could be a missed opportunity if it does not look at the wider issue

In August 2023, the British neonatal nurse Lucy Letby was found guilty of the murder of seven babies and the attempted murder of six others, at the Countess of Chester Hospital between 2015 and 2016.

It emerged through her trial – one of the longest and most complex in British legal history – that Letby had killed seven babies by injecting them with air, overfeeding them, poisoning them with insulin and assaulting them with medical tools. Letby was sentenced to life imprisonment with a whole life order meaning she will spend the rest of her life in prison with no chance of early release. She is now appealing that decision. At the same time, the Crown Prosecution Service has confirmed that there will be a retrial on one of the six counts of attempted murder where the original jury could not reach a verdict. But that trial will not be conducted until after the Court of Appeal decide whether to grant Letby an appeal against her existing convictions.

The Cheshire constabulary has since announced a corporate manslaughter investigation into the Countess of Chester hospital and specifically said they will examine senior leadership and decision-making to determine if there was criminality related to this case. The police are also looking into other babies that had been in the care of Letby who may also have been impacted; this includes at the Liverpool Women's Hospital where Letby worked from 2012 to 2015.

And finally, after Letby's conviction the Government ordered an independent public inquiry into the circumstances surrounding the murders. The scope will extend to “how concerns raised by clinicians were dealt with”. The Government subsequently confirmed that the inquiry would be a statutory inquiry which provides power for the Chair – Lady Thirwell – to compel witnesses to testify. The terms of reference for the inquiry focus primarily on the circumstances at the Trust albeit there is some limited extension to consider wider maternity considerations.

That is a high-level overview of the circumstances and issues that surround this case. Thankfully, it is rare to see this type of case where a medically qualified person abuses their power and position to inflict serious harm on patients. There have been few similar reported cases in the UK. The most notable ones in recent times have been Harold Shipman – a General Practitioner who was found guilty in 2000 of murdering 15 patients by lethal injection; and Nurse Beverley Allitt who was found guilty in 1993 of four counts of murder, and 11 counts of causing grievous bodily harm.

The need for a wider inquiry

Given the rarity of such cases, readers may think that such cases are so far removed from general issues of patient safety, including avoidable harm whether arising from negligence or not, that they should be treated separately from everyday patient safety issues. However, whilst the Letby case does seem to fall within that extreme category, I will argue that actually there were characteristics and patterns in this case that are only too familiar to those with experience in patient safety issues and that the scope of the public inquiry should be extended to ensure that those wider patterns, themes and issues are identified and appropriate action taken. We believe with the inquiry only focusing on the circumstances of the Countess of Chester hospital in isolation would be a missed opportunity to extract wider learning for the UK healthcare sector as a whole. This is not to say that we do not welcome the inquiry that has been announced as we do; it will hopefully provide important answers to the parents and families who lost much loved babies. And it will shine a light on practices at the hospital which no doubt will be changed and improved. But there is a missed opportunity here to think system-wide about changes and improvement, not least around leadership, governance, whistleblowing and a “just culture” where the failings identified here are very often mirrored in other patient safety issues and concerns we at AvMA routinely see and where the root cause is not a rogue healthcare worker seeking to deliberately harm, maim or kill patients in their care.

A just culture

The National Health Service (NHS) promotes the concept, across their entire organisation, of a “just culture” ⁱ . As part of the NHS’ Guide to a Just Culture, they publish the following on their website ⁱⁱ pages:

In June 2018, the Professor Sir Norman Williams's Review ⁱⁱⁱ into Gross Negligence Manslaughter in Healthcare report stated ‘A just culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution’. The report goes on to say ‘‘…generally in a just culture inadvertent human error, freely admitted, is not normally subject to sanction to encourage reporting of safety issues. In a just culture investigators principally attempt to understand why failings occurred and how the system led to sub-optimal behaviours. However a just culture also holds people appropriately to account where there is evidence of gross negligence or deliberate acts’.

AvMA is also listed in the same document as one of the NHS’ partners in this regard. Indeed we do support the development and embedding of such a culture which is seen as a central pillar of developing the right mindset for dealing with patient safety incidents. In fact, we go further in arguing that central to any “just culture” must be patients, including those who are harmed. The NHS Constitution starts with the words “the NHS belongs to the people” so it must follow that patients need to be at the heart of its culture.

We, like many other bodies concerned with patient safety issues and concerns, recognise that the factors that contribute to an adverse event are seldom isolated to staff failings and are often much more complicated and often involve the interplay with systems and processes and human interactions, which combined, generate the failing. We support the development around “human factors” recognising as it does this interplay of system and process design with how humans interact with them and how flaws in these designs often contribute to safety concerns and issues.

However, from this ideal culture promoted by the NHS, we need to turn to the evidence on the ground of culture in practice. And here again, we can look across the whole NHS courtesy of the annual NHS staff survey last reported in the autumn of 2022 ^iv and based on the experiences of 636,000 employees. This represented a 46% response rate from across 264 NHS organisations including 215 Trusts. Recognising that assessing and measuring organisation culture is not a precise science, some of the evidence from this survey provides useful insights into the state of the culture across the NHS today.

Here are few of the results we find interesting. Under “We are compassionate and inclusive” 74% of respondents said the care of patients/service users is their organisation's top priority. This had dropped from 79.5% in 2019. As a corollary, 1 in 4 – or 26% - did not think it was their organisation's top priority.

When it came to clinical safety, 71.9% of respondents said they would feel secure raising concerns about unsafe clinical practice and 56.7% were confident their organisation would address their concern. Here again the corollary is that 43% – nearly half – of those surveyed lacked confidence that their concerns would be addressed about unsafe clinical practice.

More specifically when it came to patient safety, the survey revealed that 33.5% of staff said they had seen errors, near misses or incidents in the last month that could have hurt staff and/or patients. Sixty-seven percent of staff reported that when errors, near misses or incidents are reported, their organisation takes action to ensure they do not happen again. However, only 59.8% of staff reported that they are given feedback about changes made in responses to reported errors, near misses and incidents.

These are just some of the responses from the survey. And whilst I have selected just a few answers, be assured that other sections relating to morale, engagement and staff pay do not fair terribly well either. Of course, this a national survey and if one were to drill into these results at an NHS organisational level, there are bound to be local differences and outliers. But there is enough data here from a large survey that suggests that staff are not feeling like they are working in a just culture across much of the NHS, regardless of which part or organisation they work in. Understanding this and addressing it is vital as no amount of patient safety management will work effectively if the culture that supports it is not effective and indeed may be adversely impacting it.

Leadership

Closely associated with issues of culture are ones of leadership. It is often said that leaders determine and shape the prevailing culture. In the aftermath of the Letby verdict news stories emerged from interviews given – both off and on the record – to the British media about attempts that were made early on to find the root cause of the increasing number of neonatal deaths that were occurring in the Countess of Chester Hospital. What has emerged so far, is the suggestion that a number of senior doctors and consultants had identified, as a common factor, Lucy Letby shift patterns of working being associated with each unexplained death at the hospital in the neonatal unit. Letby was initially removed from working in the unit but following a review by managers and other clinicians, was reinstated into her role. Those who had spoken out against Letby were subsequently made to write an apology to her for wrongly “accusing her”. The suggestion behind this action is that the leaders in the hospital were concerned about the reputation of the hospital and put this above patient safety concerns. The full facts of this issue will no doubt be explored at the inquiry and hopefully, we will get to the substance of this issue in time. But it is notable that the Cheshire Constabulary have, in the meantime, launched an inquiry into corporate manslaughter at the hospital which would suggest that there are some concerns about how senior leaders behaved and how, and with what motive, they acted.

Speaking up

The issue of people who speak up brings me to the issue of whistleblowing and here we should firstly recall that just 56.7% of NHS staff surveyed were confident that their organisation would address their concerns. There is not a specific question in the survey about whistleblowing, but the other data in the same survey points to a culture, which despite the aspirations for it to be “just” is not realised nor recognised on the ground by many staff. This is sadly compounded by the many examples of NHS healthcare workers who have felt the need to speak out and whistle blow about issues that cause them concerns – a right afforded them in law – only to find that they became the victim and were “hung out to dry” by their employer and lose their job. The NHS has taken a number of steps and initiatives to improve this situation but there must remain a concern culturally where so many staff harbour concerns about speaking up, despite these initiatives. Again, a wider scope of public inquiry is needed to examine this issue across the NHS as this is not isolated to just the Countess of Chester hospital.

Governance

Soon after the Letby verdict broke, stories also emerged that suggested that Board members – or at least the former chairman of the Board - had not been fully informed about all the relevant evidence by senior leaders around the Letby situation and their attempts to identify the root cause. This begs further questions. Not for the first time we will go into a public inquiry with questions to ask about what a Board knew and what action they took. Other public inquiries into Trust failings have sometimes found that a key issue has been a failing by the Board who took their eye off the ball. So, we need to know whether we have governance failings in this case and if we do, are they systemic rather than isolated to this Trust. But without an inquiry with a much wider scope, it will not be easy to identify if governance changes across all NHS Trusts and bodies are needed or not.

Conclusion

The Letby case is an appalling – and thankfully – rare stain on the NHS. However, it would be missed opportunity to have an inquiry that isolates its considerations to the specifics of this case and what went wrong. It misses the opportunity to identify the themes and patterns of wider issues related to NHS culture, leadership, whistleblowing and governance which plays such an important part behind many patient safety issues we at AvMA see day in day out. We applaud the efforts being made by the NHS to update and improve its patient safety learning approach through its new patient safety investigation review framework (PSIRF). ^v But it would be an opportunity lost if we fail to use this terrible and tragic case to make a real step change to the wider culture and safety in the NHS,.

Paul Whiteings Chief Executive Action Against Medical Accidents (AvMA) [e-mail]