We now know that Lucy Letby is a murderer, responsible for the deaths of seven babies and the attempted murders of six more. But as unimaginable as her crimes were, this verdict raises as many questions as it answers. Letby was not working in a vacuum. Could the killings at the Countess of Chester Hospital NHS Foundation Trust have been stopped sooner? Did organisational failures cost the lives of babies who could have been protected?
The timeline gives us a clue. The first killing for which Letby has been convicted occurred on 8 June 2015, and yet she was not removed from clinical duties until June 2016. The trust did not ask the police to investigate until May 2017. This is despite the fact that a suggestion of foul play was first raised after babies experienced insulin poisonings in August 2015 and April 2016 – more than a year before the police were called in.
Testing showed the insulin was synthetic, and had been administered when no baby on the unit was prescribed it, ruling out accidental administration and suggesting deliberate poisoning. Letby was one of the staff who could have been responsible, and consultant paediatricians and the unit manager became suspicious of her.
Doctors told the court that they had raised repeated concerns about Letby from October 2015 onwards. The court heard that the director of nursing and board safeguarding lead, Alison Kelly, the medical director, Ian Harvey, and the associate director of nursing, Karen Rees, were informed. But Letby was allowed to continue working with babies. Further unexplained deaths and collapses occurred. Doctors told the court there was pressure from senior managers “not to make a fuss”.
This would not be the first time that the NHS was slow to react. Opportunities to intervene were missed in the Gosport hospital scandal, and in the Harold Shipman and Beverley Allitt cases. The 1994 inquiry into the Allitt killings criticised an 18-day delay in acting upon laboratory evidence of insulin poisoning, during which a further child died and three other children were harmed. It criticised a general failure to be alert to abuse and to piece together all the medical clues pointing to abuse. The inquiry concluded that understaffing, and failures of postmortem examination and testing also contributed to the failure to stop Allitt sooner.
Were those lessons learned? Similarities between Letby’s and Allitt’s cases suggest not. In 2002 a seminal NHS report about learning from “adverse events” and not repeating mistakes was published, entitled “An Organisation With a Memory”, and yet NHS scandals continue to erupt with regularity. Unsafe staffing levels are the norm, despite repeated recommendations to the government on safe staffing. Political management of the NHS is a barrier to safety.
A public inquiry into poor care at Mid Staffs hospital found that a fear of “embarrassing the minister” inhibited openness about failure and therefore learning. Other reviews concluded that senior NHS managers ultimately looked “up” to the Department of Health, and not “out” at patients and communities, and that the NHS lacked professionally trained managers.
More than 20 years ago, the Bristol Royal Infirmary public inquiry recommended NHS managers should be regulated: they have dodged this bullet. A mechanism for disbarment for serious misconduct recommended by the 2019 Kark review was rejected by NHS England and the government. Recycling of failed senior managers into new jobs continues to bring the NHS into disrepute.
In June 2016, Letby’s hospital trust commissioned a review of neonatal care by the Royal College of Paediatricians after “concerns about increasing neonatal mortality”, which oddly did not feature a case-note review. This prevented detailed examination of the deaths, which should have been the prime objective. The college reported “extremely positive relationships” among staff but “remote” relationships with executives.
Astonishingly, the college’s report seemingly did not explicitly acknowledge a possibility of deliberate harm (though there is an unexplained redaction of the published report, and the word “allegation” also appears in relation to doctors’ concerns). This is despite admitting that CCTV was installed “without explanation”, unsettling some staff, and that the trust had analysed staff access to the unit.
Nevertheless, the college raised concern that not all deaths were followed by postmortem investigations – as they should have been, according to guidelines – and that where postmortems did take place, they did not include systematic blood tests and toxicology. It noted concerns from obstetrics staff about four unexpected deaths. It made reference to resolving “the personnel issues” by independent expert review of the deaths.
In the coming days, there will be many questions. Why did it take so long for the hospital to refer matters to the police? Were doctors pressured not to persist with their concerns about Letby? How many trust board members knew there was a possibility of deliberate harm but failed to act?
Perhaps there will also be reassessment. Following the verdicts, the hospital’s current medical director, Nigel Scawn, said it had made “significant changes to our services” since Letby’s arrest, and that “lessons will continue to be learned”.
The competence of NHS senior management, from the government down, is unequal to the enormous responsibility for millions of lives. Bad news is systemically minimised, often making situations worse. Failure is, in fact, a valuable governance tool and, if competently managed, a path to improvement. Yet the NHS perversely seems to reward failure, even as it attacks whistleblowers.
Until this changes and there is better law to protect whistleblowers, we will continue to see disasters like this one, and tragedies such as befell those whose babies died and suffered harm in Chester.
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Minh Alexander is a retired consultant psychiatrist and NHS whistleblower
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