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Letby inquiry must have teeth but not succumb to pressure for unnecessary change


4 min read

The announcement that there will be a statutory inquiry into the murders committed by Lucy Letby is another important step on the road to justice for the families so tragically affected by this case.

Whilst her behaviour has been confirmed as criminal, there is clearly a wider story of multiple failings in the NHS that needs to be explored. 

During her trial we heard compelling evidence from very senior staff who worked closely with her. They told the court how they felt completely let down by hospital management who failed to take their concerns seriously and failed to act quickly enough to prevent further deaths. We heard how the concerns of frontline staff were met with a management response in May 2016 (after five murders) which comprised of a two-page document, starting: “There is no evidence whatsoever against LL [Lucy Letby] other than coincidence”.

What is needed is a massive change in the mindset and culture of NHS management when faced with allegations of patient harm of whatever kind

The families impacted, Letby's former colleagues and the public at large quite rightly want lessons to be learned so that nothing like this ever happens again. There is no doubt a statutory inquiry is the right way to determine those lessons and the public want to see the relevant management compelled to attend and give evidence under oath. 

Equally, given the past conduct of NHS staff such a move was wise. The Essex Mental Health Independent Inquiry chair, Dr Geraldine Strathdee was essentially forced to convert her inquiry into a formal statutory inquiry after the hugely disappointing response from staff who were asked to give evidence voluntarily. Incredibly of the 14,000 staff written to in that matter, only 11 initially said they would attend to give oral evidence.

It is absolutely right the government shows that the Letby inquiry will have teeth. There will also be many calling for tangible results to such a lengthy and expensive exercise. Yet the record of health-related inquiries in this country has not always been an impressive one. Whilst the Shipman inquiry set up in 2001 produced tighter governance in relation to the certification of death, the mechanism to fully implement this was only finally contained within the Health and Care Act – passed into law in May 2022. This has paved the way for the statutory medical examiner system which the Shipman inquiry recommended in its report of 2002 – a full 20 years before it was eventually implementated. The final system is however still not quite what was initially envisaged.

The Gosport Hospital report ascertained that more than 450 people had their lives shortened at the hospital and another 200 were “probably” given opioids between 1989 and 2000 without any medical justification. Whistleblowers reported their concerns in 1991 but the overprescribing continued for over nine years. The incidents that occurred between 1987 and 2001 were of great public concern and yet no criminal prosecutions were undertaken nor were any successful GMC cases brought. Changes have been made to the pharmacy systems since the 1990s (mainly through increased used of IT which would have occurred in any event) which means that such a high level of overprescribing would probably be caught far earlier now.

Although the Letby inquiry will find itself under pressure to produce recommendations and changes, it is possible such changes may take another 10-20 years to implement and take up vast amounts of valuable time through consultations and committees.  The starting point, I would suggest, should be to consider what impact Letby would have had if staff had been listened to at the outset, had the first three deaths been fully examined in forensic detail, and had Dr Brearey’s crucial first meeting with managers on 2 July 2015 been fully focussed on patient safety.

Before making recommendations which increase clinical bureaucracy and mandatory staffing levels in neo-natal wards, the inquiry needs to pause and reflect. It would be regrettable if the inquiry felt under pressure to give rise to a set of stringent new regulations and paperwork which impose an extra burden on hard working, caring frontline doctors and nurses simply doing their job. 

From the evidence we have already heard, there seems to be an argument that the current system, if properly adhered to, should have caught Letby quickly. Hence the focus of the inquiry should be the reasons why it did not, rather than recommending change in clinical practice on the basis of a highly exceptional case.

More usefully, what is needed is a massive change in the mindset and culture of NHS management when faced with allegations of patient harm of whatever kind. What patients and clinical staff don’t need is change for the sake of it. There must be a laser like focus on management failings and very careful thought before remotely considering an increase of the burden on doctors and nurses.


James Bell, head of medical negligence at Kingsley Napley LLP law firm

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