When James Titcombe heard that Lucy Letby had been able to continue harming babies despite doctors sounding alarm bells, he felt a terrible sense of deja vu.
To the father of a nine-day-old boy who died avoidably due to failings in the NHS, the culture of denial, the failure to properly investigate patient harm and crackdowns on whistleblowers at the Countess of Chester hospital that ultimately left Letby free to kill were sadly “only too familiar”.
Fifteen years after the death of his baby son Joshua, in what subsequently became known as the Morecambe Bay maternity scandal, the NHS has been rocked by yet another baby deaths disaster.
“It’s heartbreaking,” he tells the Guardian. “Every NHS scandal in recent history has highlighted the importance of a culture that supports and encourages staff to speak up about safety concerns, and the need for leaders to listen and act appropriately when they do. Yet here we are again.
“Another example of lives that could have been saved had the concerns of staff been heeded sooner. Another example of where those raising concerns quickly found themselves the focus of detrimental action while the concerns themselves were effectively hushed away.”
The seven tiny lives lost in the Letby case were due to a deliberate intent to cause harm, and not a result of unsafe practice, as was the case in the other baby death scandals that have plagued the NHS. But the Letby case is yet another stain on the reputation of NHS maternity and neonatal services, and there are alarming patterns being repeated that Titcombe and others warn must be addressed.
“The doctors who worked with Letby repeatedly blew the whistle, but by all accounts, senior leaders at the trust appear to have responded with a ‘reputation first’ approach, more concerned with managing potentially ‘bad news’ than thoroughly investigating the concerns being raised,” he says.
“At one stage, after Letby had already murdered six babies, managers upheld Letby’s grievance against the doctors, who were then made to apologise, and Letby was allowed to return to the unit to continue her campaign of harm.
“In Joshua’s case and in the case of other high-profile maternity failures, avoidable harm to mothers and babies resulted from unsafe practice, dysfunctional teamwork and failures in leadership and governance rather than wilful intent. However, themes in terms of how the leadership at the Countess of Chester responded to emerging concerns are only too familiar.”
Joshua died in 2008 after staff at Furness general hospital failed to pick up on signs of an infection for almost 24 hours. Titcombe’s efforts to find out what went wrong were constantly hampered and medical records went missing.
His campaign for answers resulted in a major inquiry being set up in 2013 by the then health secretary, Jeremy Hunt. It found a decade-long “lethal mix” of failings at almost every level, and concluded that services for babies were beset by a culture of denial and collusion.
Bill Kirkup, who led that inquiry, told the Guardian he recognised precisely the same issues in the Letby case and said he was “frustrated” that “we have still not learned the lessons” from Morecambe Bay and other NHS baby scandals.
Two more inquiries since Morecambe Bay have laid bare yet more serious failures that led to babies being harmed or dying at Shrewsbury and Telford and at East Kent NHS hospital trusts.
A fourth inquiry, into Nottingham hospital trust, is under way. Natalie Cosgrove, a partner at Ashtons Legal who has worked with some of the affected families, said: “I feel for any parent who delivers in the NHS right now, as maternity is not as safe as one is led to believe for so many reasons.
“But not least because it has been systematically defunded, deskilled and overmanaged to the point where even when you have decent acuity levels [the amount of care a patient needs], the culture is often so toxic that what should be a positive experience for families is anything but.”
Earlier this month, a report produced by the Nursing and Midwifery Council, seen by the Guardian, sounded the alarm over poor workplace cultures in NHS maternity services.
Some midwives are not always speaking up when they see something that is not right, and not communicating well enough with colleagues or people in their care, according to the regulator.
“It would be scaremongering to say that babies are not safe within neonatal care, but equally, if you don’t improve the culture … then the same problems will occur. We do know that hospitals have a habit of putting reputation management first and foremost,” said Cosgrove. “They can and must deal with that, because otherwise the opportunity for unsafe practice, or intentional harm as in the case of Letby, remains.”
She added: “If trusts read what happened in Chester and are not seriously reflecting, then we are in very worrying times. No hospital should turn their head the other way. There is a responsibility now for all.”
Last week the government announced a new inquiry, into how Letby was able to murder seven babies and attempt to kill six others. Pressure has been mounting from bereaved families and experts to strengthen the investigation to a statutory inquiry where witnesses would be compelled to give evidence.
Kirkup said his frustration over the failures in the Letby case was rooted in two main similarities with other NHS baby death scandals. Both are still recurring problems in the service, he warned.
“The first is the unwarranted delay in acknowledging that there was a serious problem that demanded urgent investigation, a striking feature of all the recent maternity and neonatal scandals. Either families, clinicians or both knew for far too long that there were problems before others accepted or admitted it.
“The second is the immediate reaction by those in charge to put the reputation of the organisation and themselves ahead of being open and honest. The effects of denial, deflection and sometimes dishonesty are stark, making even worse the distress to those harmed.”
In the wake of Joshua’s death, Titcombe made a conscious decision to try to help other parents avoid the pain he went through.
Previously a project manager in the nuclear industry, he switched to a career in healthcare safety, and is now the chief executive of Patient Safety Watch. The organisation carries out research into the levels of preventable harm in healthcare systems and campaigns for improved patient safety in the NHS.
Sadly, even in 2023, there is clearly still a need for such work. Nine days before Letby was convicted, another maternity unit was given the lowest possible rating by the Care Quality Commission after the regulator described it as a “chaotic environment which was not fit for purpose”.
Hull Royal Infirmary, which forms part of the Hull University Teaching Hospitals NHS Trust, had its maternity rating downgraded from good to inadequate.
In the wake of Morecambe, Shrewsbury and Telford, East Kent, Nottingham, and now Chester, the report makes for chilling reading. Staff felt unsupported, telling inspectors that “they were not always listened to and following incidents they were not provided with compassion and support from leaders, which can be indicative of a closed culture”.
Titcombe, 45, says we need to take an urgent look at the system pressures that influence the culture and behaviour of NHS trusts.
“What drives organisations towards ‘comfort-seeking’ behaviours rather than ‘problem-sensing’? I think the truth is that the wider system doesn’t always reward NHS organisations who are transparent about their problems, and we need to turn this on its head.
“Healthcare, particularly maternity care, is complex. The measure of a safe and a well-run organisation isn’t one that purports to have no problems – it’s one that constantly seeks out safety issues and concerns, openly acknowledges and acts on problems and encourages and rewards everyone who plays a part in doing all of this to keep patients safe.”
