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What went wrong with the management of Letby

It is undoubtedly one of the worst tragedies to hit the NHS in it's 75 year history that Lucy Letby was enabled to continue her killing spree for such a protracted period of time. But then this is nothing to the tragedy experienced by the parents of the babies she has been convicted of killing and the families of the babies she may yet be proven to also have killed.


We can't pretend to understand what drove Letby to do what she has done, but we need to learn the lessons from the parlous response that the hospital executive had toward the suspicions of their own consultants at the Countess of Chester.


Lesson 1: just because it might hurt is not a reason to do nothing. There is little doubt that those managers who decided not to investigate the suspicions of the doctors about Letby did so to protect the reputation of the trust. What a disastrous decision that has proven to be for the babies killed later as well as for hospital and the NHS at large.


2. All it takes for evil to triumph is for good people to do nothing. This old chestnut of a saying absolutely captures the reality of this situation.


3. If you are not going to act on whistleblowing, then why have a policy? Like all initiatives in the health and social care sector, whistleblowing is only as good as the actions which arise as a result of it.

4. People working in health and social care need integrity to blow the whistle when they see something is not right and the courage to step outside of the system when the system is failing. While we don't know that whistleblowing to the CQC or the police would have changed any outcomes, people within health and social care need to be empowered to step out of the usual processes when they truly believe those processes to be failing.


5. Cultures within health and social care need a drastic shake up. Any culture where several manager collude to cover up what was happening is not a culture within which we anyone would want to be cared for. It is not enough for the CQC, https://www.cqc.org.uk/assessment/quality-statements/safe/learning-culture,to pose quality statement like:


We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We have to fine ways to cultivate these cultures in reality and to inspect for them proactively.



6. Terrifyingly, the duty of candour, https://www.cqc.org.uk/guidance-providers/all-services/duty-candour-notifiable-safety-incidents, appears to have been completely ignored by the hospital executive, with no-one considering it their duty to own and say sorry for the deaths at the time in which they occurred.


There is little doubt, that this sad story will run and run with many commentators passing their opinions and many people involved and at the fringes of the events giving their reasons for what they did and what they failed to do.


It seems that the lessons of Climbié, Baby P, Mid--Staffs, winterbourne view and a host of other events like them have not been learnt. Such events cast a long and shameful shadow over health and social care provision in the UK and pose questions about how such things can happen time and time again?


There is no doubt that Letby is singularly responsible for her own actions and the evil premeditated murders of the seven babies. But, there is also little doubt that the misguided hierarchical structures within the NHS as well as cultures which chase targets and ratings rather than cultures which put people first are to blame for perpetuating what happened at the Countess of Chester Hospital.


Such cultures are created by people not places and such cultures can exist anywhere, hospitals, care homes, hospices, domiciliary care services where people are not empowered to speak up and where managers lack the courage to act. Surely it is better to act on a suspicion and be proven wrong than to perpetuate evil through inaction or worse?







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