In light of the recent verdict in the Lucy Letby trial, it has become apparent that in this case, management at the Countess of Chester Hospital in Cheshire potentially could have, and should have, done more once concerns were raised by staff.
Concerns had been raised by Letby’s colleagues to management after they noticed she was the only member of staff to be on shift at the time of all unusual deaths. When concerns were raised after the death of child I in October 2015, Dr Ravi Jayaram was told by management ‘not to make a fuss’.
Following what we now understand to be a further two murders, and a number of attempted murders, Dr Stephen Brearey phoned the Duty Executive to request Letby be removed from the unit. However, this was refused, and it was insisted that not only was Letby safe to work, but the Duty Executive was happy to take responsibility if anything happened to other babies when Letby was involved.
Even when Letby was removed from the Neonatal Unit at the hospital, she was moved to the risk and patient safety office. Here, she had access to sensitive documents from the neonatal unit and was near senior managers whose job it was to investigate her.
She was due to return to the neonatal unit in March 2017, but this was halted as the police were contact by the hospital. Three years after the first concerns of Dr Brearey were raised, Letby was convicted in 2018. Following a 10-month trial, which began in 2022, Letby has now been found guilty of murdering seven babies and attempting to murder six others. She will spend the rest of her life in custody.
Following this case, questions have been raised about the handling of the situation by the management involved. Could deaths have been prevented if swifter and more appropriate was taken when staff raised concerns? Could some of the horrific events have been prevented? And could this now be a time to reflect, and to start regulating NHS management as we do with doctors and nurses?
Time to reflect
Dr Stephen Brearey, the first of Letby’s former colleagues to raise concerns about her, told BBC Radio 4’s Today programme there was ‘no apparent accountability’ for what NHS managers do in trusts.
He continued to say that instead of acting on the warnings raised by himself and his colleagues, their lives were made very difficult, to the point they felt under attack; ‘You go to senior colleagues with a problem, and you come away confused and anxious,’ Dr Brearey stated.
Dr Brearey also stated that what he and his colleagues had experienced was not uncommon in the NHS. He said he’s been contacted by clinicians from all over the UK who told him; ‘Clinicians raised concerns with senior members of the hospital and their lives were made very difficult by doing that’.
‘I can’t emphasise enough how difficult a position this puts the clinician in,’ he continued. ‘Carrying out your clinical practice in that environment is very difficult.’
The consultant also commented: ‘Doctors and nurses all have the regulatory bodies that we have to answer to, and quite often we’ll see senior managers who have no apparent accountability for what they do in our trusts and then move to other trusts.’
Dr Brearey is concerned about senior managers’ future actions, as he added; ‘There doesn’t seem to be any system to make them accountable, and for them to justify their actions in a systematic way’.
Whistle blowers should be protected
This is a truly tragic case with a tragic set of circumstances. One of the many things that have come to light during and following the Letby trial, is that whistle blowers within the NHS need to be better protected; especially where patient safety is concerned. Many hospitals, like the Countess of Chester, require cultural changes; including hierarchical command and control management style. There was a delay in investigating the concerns raised by doctors since June 2015, at the time when only two babies had died.
Dr Brearey is quite right to point out that currently, those in senior management roles within the NHS who may or may not have clinical experience themselves, do not have a regulatory body to answer to. Having a regulatory body would enable a safe working environment that allows for doctors and nurses to speak up, voice their concerns and have those concerns listened to. It would protect patients from any risk to harm, as decisions made by senior managers will be scrutinised by the competent standards set and this will provide a culture and environment that allows for safe and effective care.
Patient safety has to be the priority. Senior managers in hospital Trusts have to move away from a culture of blame, and where serious questions about patient safety are raised, they have to put those first rather than the reputation of the Trust. The concerns raised by the doctors in this case were medically complex and their concerns as to the number of babies who suddenly collapsed and later died or sustained a serious injury, required senior managers (most of whom do not have adequate medical or clinical experience themselves) to carefully listen to the doctors’ concerns, and the clinical information available to them, as to the possible causes of these collapses. They were simply ignored.
In 2016, an external review was scheduled to take place. It didn’t. The police should have been notified about the deaths as early as 2015. They weren’t. There were multiple opportunities for the senior managers to meet with the doctors who requested to meet with senior managers time after time, to take action and to have police involved much sooner. They didn’t.
Fear of retaliation came before patient safety
As the deaths were not properly reported to NHS, should the NHS have had better systems in place which provide an alert to senior managers within a Trust when unexplained baby deaths over a certain period occur? Could this have prompted an external investigation, including forensic investigation, or at the very least, an internal investigation?
There was clear negative management attitude, inaccurate estimations of the severity of misbehaviours, fear of retaliation and cultural barriers.
The President of Royal College of Nursing Sheila Sobrany tweeted that ‘…racism is part of the reasons why whistle-blowers were ignored… If we are going to learn anything from this case we need to stop denying that racism is a serious issue in the NHS, this doctor would have been listened to if he was white and Lucy Letby would have been stopped sooner if she wasn’t white… This was a serious safeguarding issue that compromised the lives and well-being of babies and subsequently their parents. Dr Ravi Jayram was not listened to or taken seriously.’
Race may have played a role, but it wasn’t the only or the significant reason why senior managers failed to investigate the doctors’ concerns promptly and carefully
Staff who speak out about problems or concerns at work, especially where those compromise patient safety, need to be protected from retribution of any kind.
I echo the words of Dr Ravi Jayaram who was one of the hospital staff that became aware of the rise in sudden and unexpected collapses, and raised those with senior managers; ‘The safety of patients should come above any risk of reputational damage…’
It is not unfortunately the first time we are talking about senior managers within the NHS and whistle blowers. After the Robert Francis inquiry looking into the deaths at Mid Staffordshire Hospitals, NHS managers know what needs to be done. A decade on, we are still talking about the same issues; such as managers being in denial, about the nature and extent of the problems, staff and patient concerns repeatedly ignored in favour of balancing the books, managers focusing more on the reputation of the Trust than the quality and safety of care, and even the protection of whistle blowers.
No mother, father, sibling or family member should lose a child, or have a child that comes into significant harm, simply because senior managers within the NHS are more interested in making the issue go away and trying to protect the Trust’s reputation.
Will lessons be learnt?
Currently, there is no proactive legal duty to protect whistle-blowers in the UK. Downing Street has ordered an independent inquiry into the Letby Case and has said it would not rule out putting it on a statutory footing – though they haven’t confirmed they will. I welcome an independent inquiry, and one that can compel key witnesses, whether statutory based or not, to give evidence so that families can have the answers they so desperately deserve and can finally began to grieve.
There are many questions raised in this case, such as why the Trust didn’t investigate multiple concerns raised in 2015, and again in 2016. Why wasn’t there an external investigation in 2015/2016? Why weren’t the police involved when more unexplained baby deaths and harm were reported? Why did the NHS’s Duty of Candour fail here?
Importantly, my most sincere condolences are with the families involved in this most devastating of cases. I hope that the verdict goes some way to allowing those grieving to at least start the difficult journey of moving forward.
But lessons desperately need to be learnt, so that this tragedy never happens again.
Parbeen is an Associate of Fletchers Solicitors, part of Fletchers Group. This article was originally posted on the Fletchers Solicitors website. Under Fletchers Group, Parbeen represents many birth injury clients of Patient Claim Line