We now have knowledge of Lucy Letby’s status as a murderer, accountable for the deaths of seven babies and attempted murders of six others. However, as heinous as her crimes are, this verdict raises numerous questions. Letby did not act alone. Could the Countess of Chester Hospital NHS Foundation Trust have prevented these killings? Did organizational failures contribute to the loss of lives that could have been protected?
A timeline provides some insight. The first murder for which Letby has been found guilty occurred on June 8, 2015, but she was not relieved of clinical duties until June 2016. The trust did not involve the police until May 2017, despite suspicions of foul play arising from insulin poisonings in August 2015 and April 2016 – over a year before police were called.
Tests confirmed the presence of synthetic insulin, which had been administered without a baby being prescribed it, ruling out accidental administration and suggesting intentional poisoning. Letby was among the staff members who could have been responsible, and both consultant pediatricians and the unit manager grew suspicious of her.
Doctors testified that they had consistently raised concerns about Letby from October 2015 onward. The court heard that Alison Kelly, the director of nursing and board safeguarding lead, Ian Harvey, the medical director, and Karen Rees, the associate director of nursing, were informed. However, Letby was allowed to continue working with babies, leading to more unexplained deaths and collapses. Doctors also revealed that there was pressure from senior managers to not cause trouble.
This wouldn’t be the first time the NHS has been slow to react. The Gosport hospital scandal, as well as cases involving Harold Shipman and Beverley Allitt, saw missed opportunities for intervention. The 1994 inquiry into the Allitt killings highlighted an 18-day delay in responding to laboratory evidence of insulin poisoning, during which another child died and three others were harmed. It also criticized a general failure to recognize and piece together the medical clues pointing to abuse. The inquiry concluded that understaffing, inadequate postmortem examinations, and testing contributed to the delay in stopping Allitt.
Have we not learned from these lessons? The similarities between Letby’s case and those of Allitt suggest otherwise. In 2002, a significant NHS report titled “An Organisation With a Memory” was published, emphasizing the importance of learning from adverse events and avoiding repeating mistakes. Yet, scandals within the NHS continue to occur regularly. Despite repeated recommendations on safe staffing, unsafe staffing levels persist. Political management of the NHS remains a barrier to safety.
The public inquiry into poor care at Mid Staffs hospital revealed that a fear of embarrassing higher-ranking officials hindered transparency about failure and, consequently, hindered learning. Other reviews concluded that senior NHS managers primarily directed their attention upward, towards the Department of Health, rather than outward, towards patients and communities. The NHS also suffers from a lack of professionally trained managers.
Over 20 years ago, the Bristol Royal Infirmary public inquiry recommended regulating NHS managers, but this has been ignored. A disbarment mechanism for serious misconduct, suggested by the 2019 Kark review, was rejected by NHS England and the government. The recycling of failed senior managers into new positions continues to tarnish the reputation of the NHS.
In June 2016, Letby’s hospital trust commissioned a review of neonatal care by the Royal College of Paediatricians. This review aimed to address concerns regarding increasing neonatal mortality. However, it oddly did not include a thorough examination of the deaths, which should have been the primary objective. The report highlighted “extremely positive relationships” among staff but noted distant relationships with executives.
Surprisingly, the college’s report did not explicitly acknowledge the possibility of deliberate harm, even though certain unsettling factors were highlighted, such as the installation of CCTV without explanation and scrutiny of staff access to the unit. The report did raise concerns about the lack of postmortem investigations following deaths, as well as the absence of systematic blood tests and toxicology in postmortems. Obstetrics staff also expressed concerns about four unexpected deaths. The report suggested addressing “personnel issues” through independent expert review of the deaths.
In the days to come, many questions will need answers. Why did the hospital take so long to involve the police? Were doctors pressured to suppress their concerns about Letby? How many trust board members were aware of the possibility of deliberate harm but failed to take action?
Hopefully, there will also be a reevaluation. Following the verdicts, the hospital’s current medical director, Nigel Scawn, stated that significant changes had been made to their services since Letby’s arrest and that lessons would continue to be learned.
Senior management within the NHS, from the government downward, is inadequately equipped to handle the immense responsibility of safeguarding millions of lives. Negative news is often downplayed, exacerbating situations. Shockingly, the NHS seems to reward failure while simultaneously attacking whistleblowers. Until this changes and better legal protection is granted to whistleblowers, we will continue to witness disasters and tragedies like the one in Chester.
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Minh Alexander is a retired consultant psychiatrist and NHS whistleblower.
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