The scale of Lucy Letby’s crimes, and the Countess of Chester hospital’s failure to act on warnings that could have halted her killing spree, means the announcement of an independent inquiry on Friday was almost inevitable.
It will have to forensically examine the failings of people and processes involved in her serial targeting of sick newborns and make detailed recommendations to ensure babies in neonatal units are much better protected.
Letby was convicted on Friday of murdering seven babies and attempting to kill six others at Countess of Chester hospital between 2015 and 2016. But she was not the first children’s nurse to attack her charges – Beverley Allitt killed, tried to kill or seriously harmed 13 children in an eight-week spree in 1991. As such, meaningful change is vital.
While it is impossible to stop a member of staff using their position of trust to murder, the NHS will have to learn lessons from this case to minimise the risk of anything like it happening again.
Experts have identified two key areas in which the NHS needs to make urgent improvements: proper investigation of concerns that staff raise about patient safety, and using data already collected by neonatal services to identify any unusual patterns in babies collapsing or dying unexpectedly.
“There is sadly a long history of whistleblowers who speak up being ignored, sidelined and blamed, and sometimes forced to pay the price of their efforts with their livelihood,” said Paul Whiteing , the chief executive of the patient safety charity Action Against Medical Accidents (Avma).
He cited examples of doctors whose fears about risks to patient care were not taken seriously by the bosses at their hospitals. Dr Stephen Bolsin , a consultant anaesthetist, could not get another job in the UK after he exposed the scandal in which dozens of children who had heart surgery at the Bristol Royal Infirmary in 1991-95 died as a result of poor care and what the resulting inquiry said was “dangerous” unsafe practice.
Dr Kim Holt, a consultant paediatrician, was put on “special leave” by Great Ormond Street children’s hospital in London after warning that its paediatric services in Haringey posed a serious risk to patient safety. Her warning came a year before staff failed to spot that Peter Connelly – who become known as Baby P – had a broken back two days before he died in 2007.
And more recently Hampshire hospitals NHS trust sacked Dr Martyn Pitman, a consultant obstetrician and gynaecologist, when he raised concerns about what he saw as inadequate staffing levels in the maternity unit where he worked.
“These are just three examples drawn from the many [such] cases. In each case, had they been listened to sooner, then almost certainly lives could have been saved,” added Whiteing.
Evidence during Letby’s trial showed that the Countess of Chester hospital trust failed to launch a formal review into the deaths until July 2016, months after concerns had been raised to executives by senior doctors including Dr Stephen Brearey and Dr Ravi Jayaram.
In July 2016, after Letby was removed from the unit, the hospital commissioned two external reviews of the unusual events in its unit. Two of the doctors who raised concerns, Brearey and Dr John Gibbs, have told the Guardian executives should have ordered an investigation months earlier and that waiting until July 2016 might, according to Dr Brearey, have cost babies’ lives.
Neither of the reviews identified foul play and, according to Brearey, the hospital relied on their findings to order the doctors to withdraw their suspicions about Letby and apologise to her.
Evidence during Letby’s trial showed that the Countess of Chester hospital trust did not properly examine concerns that Gibbs, Brearey and at least two other consultant paediatricians had raised about her.
On Friday, the Countess of Chester trust’s executive medical director Dr Nigel Scawn said: “I speak for the whole trust when I say how deeply saddened and appalled we are at Lucy Letby’s crimes. We are extremely sorry that these crimes were committed at our hospital and our thoughts continue to be with all the families and loved-ones of the babies who came to harm or died. We cannot begin to understand what they have been through.
“This case has had a profound impact on our patients and our local community and also our staff – who come to work every day determined to provide safe and high-quality care for our patients.
“Our staff are devastated by what happened and we are committed to ensuring lessons continue to be learnt.”
Doctors are under a professional obligation to report concerns in order to prevent harm to patients. But Prof Philip Banfield, the leader of the British Medical Association, said that too many who did so “have been silenced, treated unfairly or in some cases dismissed from their roles”. The system by which they alerted their bosses to what they feared were flaws in the system “needs urgent reform”.
The nature of such reform should be “a cultural and legal shift that fiercely encourages and values the act of raising concerns instead of instilling fear and punishment”, he added.
In recent years a series of changes have been introduced in England to improve safety and transparency in the NHS when failings occur, prompted by the Mid Staffordshire care scandal in the noughties and Dr Harold Shipman’s murder of hundreds of elderly patients between 1974 and 1998.
However, Banfield is worried that some of these initiatives are not being allowed to fulfil their important role. “Improvements such as the introduction of medical examiners and ‘freedom to speak up guardians’ can only work if trusts give them the proper authority and autonomy that they need to be able to function effectively. Even with these mechanisms in place, if doctors still fear harsh reprisals or think they may lose their job entirely, they will not serve their purpose,” he said.
Neena Modi, a professor of neonatal care at Imperial College London, agrees with Whiteing and Banfield that current whistleblowing arrangements are inadequate. But the former president of the Royal College of Paediatrics and Child Health (RCPCH) proposes another potential remedy.
“Trusts must be required to respond to whistleblowing and this must be prompt, expert, independent and unbiased. Should there be a central ombudsman to whom all whistleblowing must be notified? Perhaps.”
Modi also suggested that the NHS could reduce the risk of a nurse being able to attack babies in a neonatal unit for as long as Letby did by using data to quickly highlight “warning flags”, such as an unusual number of babies suffering an unexpected collapse or a sudden rise in deaths or persistently high mortality, which could indicate criminality or, more likely, poor care.
The UK is missing an opportunity to improve things because while it collects more data on neonatal care than almost any country in the world, it doesn’t do real-time analysis on it for that purpose.
Neonatal units across the UK already submit extensive detailed information to two similar but different datasets: the UK National Neonatal Research Database based at Imperial, which Modi leads, and the National Neonatal Audit programme, run by the RCPCH.
“Why are we not taking advantage of our huge strengths in high-quality health data to measure [newborn babies’] outcomes continuously over time to look for warning flags?” she said.
Referring to childbirth scandals such as those at the Morecambe Bay, East Kent and Shrewsbury and Telford NHS trusts, Modi added: “We’ve had scandal after scandal recently in relation to maternity services. Why are we not monitoring newborn deaths continuously across the country?”
Avma’s Whiteing agreed that proactive monitoring of neonatal data would reduce risk. “The NHS is awash with medical and outcome data but it still appears to be the case that this data is not effectively ‘joined together’ and effectively analysed in order to identify patterns and trends, which must have been apparent sooner in the Letby case.”
