The Lucy Letby case and the NHS

One of my grandsons was born prematurely. He was cared for, at first, in an incubator. Weeks of constant, thoughtful, professional 24-hour care eventually delivered him to his grateful parents.

There should be no safer place in the world than an intensive care neonatal unit. There is no more defenceless human being than a prematurely born child. There is no greater trust a parent can place than in the doctors and nurses caring for these fragile newborns, often no bigger than the palm of my hand.

What takes place in these units are little everyday miracles. They require complex and skilled medical interventions and trigger-fast responses. They exemplify the spirit of the Hippocratic oath which remains the touchstone of medical integrity: Do no harm.

By the time she was caught, nurse Lucy Letby had murdered seven babies and attempted to kill (at least) six more at the Countess of Chester’s neonatal unit. She was a serial killer on the loose, hiding in plain sight in the last place you’d expect to find one.

There are many unanswered questions about this chilling case. What drove ‘nice Lucy’ with a winning smile, cold-bloodedly to do this? But at the very top of the list is the question: why did the hospital management not listen to its senior clinicians when they first raised the alarm?

Trial testimony and subsequent interviews point to serious failures by the hospital’s leadership. Repeated warnings by senior doctors on the ward that they may have a killer in their midst were ignored.

On the contrary: consultant paediatricians at the hospital who raised questions about Letby after several unexplained deaths were threatened. They were then instructed to apologise to her by the hospital’s Chief Executive who was worried about the hospital’s reputation. They were in effect told to shut up.

The respected Health Service Journal this week reported that documents it had seen reveal how The Trust questioned the integrity and professionalism of doctors who raised concerns about her.

Letby was eventually removed from the ward but not until a year after the first suspicions were raised. Letters from senior consultants were ignored. The police were not asked to investigate by the trust for almost another year after that. Bureaucracy, it seems, can kill.

A (non-statutory) public inquiry follows. This time-honoured British method of shutting the stable door after the horse has bolted will in due course no doubt suggest ways of making things safer.

But corporate cold feet in the NHS – or at any rate its higher reaches, is nothing new. Neither is failure to react fast enough. It’s in the DNA.

The cases of Harold Shipman and the Gosport Hospital scandal, where patients died from opioid overdoses, come to mind. The so-called Mid-Staffs hospital debacle, in which between 400 and 1200 patients died, became a by-word for NHS care at its most negligent. We still don’t know the full truth in these cases.

The NHS is a vast organisation, exceeded globally as an employer only by Walmart (2.3m employees), China Railways (2m), China’s Ministry of Public Security and McDonalds (1.9m). It swallows up nearly £200 billion of public funds every year, or just under 10% of Britain’s GDP.

How do you run such a leviathan on a human scale? How can it allow people to be heard? How do you balance the need for administrative rigour with letting clinicians at the coal face get on with their job?

This ambivalence was perfectly caught in an astonishingly tone-deaf statement by Tony Chambers, then the Chester hospital’s chief executive. He had, according to the Guardian, spent hours talking to Letby and her parents. He concluded that she was innocent. He played detective — or perhaps God.

But then in May 2018, by which time the police had become involved, he wrote this to the hospital’s consultants:  “…the need to balance the competing priorities of the safety of babies and their families, the health and wellbeing of our staff and the reputation of our services makes it easy to question my judgment and my approach to managing these.”

Do premature babies, the health and wellbeing of staff and the hospitals reputation really weigh equally in the balance? Clearly in Chambers’ mind they did. But this, surely, is a travesty of what hospitals and the NHS are for. Their first and last obligation is to their patients and their families.

NHS England’s CEO, Amanda Pritchard, has now written to all trusts instructing NHS leaders and boards to “ensure proper implementation and oversight” of their whistleblowing processes (known as “Freedom to Speak Up”), by making sure all staff know how to raise concerns.

But the cards are stacked against medical staff. The Care Quality Commission, a body that all-too-often doesn’t dig deep enough, rated the trust as ‘Good’ in the period when concerns were raised and Letby was going about her grim business.

So, what is to be done?

I turned to Professor David Oliver, a leading NHS consultant with extensive experience on the frontline. He has held a number of medical leadership and policy roles, including advising the NHS Emergency Care Improvement Partnership working with over 30 acute hospitals and healthcare systems.

He wants to see three things happen:

• A much improved national real-time data system that flags up abnormal patterns or high rates of sudden deaths or collapses in hospital. These should all be scrutinised and reviewed by clinical peers and if necessary referred to coroners. It might have stopped Shipman.
• A “just, open and transparent culture” which doesn’t just pay lip-service to whistleblowing. Staff need to be listened to without fear of reprisal and not reflexively dismissed as vexatious. Whistleblowing, would rarely be necessary if the internal processes worked.
• A change in the “very top-down, hierarchical culture” that pervades the NHS. This inevitably encourages a clash of values between clinicians and managers. The first group is focused on their patients and role as clinical professionals. The second can become preoccupied with hitting their performance targets and keeping regulators happy, sometimes sweeping bad news under the carpet.

The NHS is an extraordinary, flawed organisation. But it is not, as its detractors claim, a bottomless pit. Nor is it especially inefficient. It has been chronically underfunded since the 2008 financial crisis. Britain spends less on healthcare as a percentage of GDP than the US, France, Canada, Holland, Belgium, Sweden, Australia and Denmark. Brexit has made an already bad staff shortage worse.

The NHS is a national treasure. It’s one of the few things that binds our nation together. It needs, like my grandson, the best clinicians and hospitals. It could also do with a fresh charter that sets its patients very clearly at the top of its priorities.

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