- Juliet Dobson, managing editor
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On 21 August Lucy Letby, a neonatal nurse, was sentenced to life in prison for the murder of seven babies and the attempted murder of six others (doi:10.1136/bmj.p1931).1 The case has raised many questions for the NHS about the systemwide implications of these deaths: why were opportunities to stop her missed, why were staff’s concerns about Letby not sufficiently acted on, and what will it take to resolve some of the deep seated problems in the NHS’s organisational culture?
Since 2015 there have been three separate inquiries into NHS maternity services: Morecambe Bay, Shrewsbury and Telford, and East Kent NHS trusts (doi:10.1136/bmj.h1221 doi:10.1136/bmj.m4797 doi:10.1136/bmj.o2520).234 A fourth into Nottingham NHS Trust is under way (doi:10.1136/bmj.p1636).5 These inquiries share common findings: lack of leadership and teamwork, poor workplace culture, inadequate staffing, and a failure to listen to and act on the concerns of staff, patients, and families (doi:10.1136/bmj.p1943).6 The Letby case also revealed a lack of systematic monitoring of neonatal outcomes at the Countess of Chester Hospital, write Bill Kirkup and James Titcombe, making it harder for doctors to convince managers to investigate when they knew there was a problem (doi:10.1136/bmj.p1972).7
Even with monitoring systems in place, NHS staff need to believe that they can speak out without fear of repercussion. After Robert Francis’s review into Mid Staffordshire NHS Trust the National Guardian’s Office was set up and NHS “freedom to speak up guardians” were created in every trust (doi:10.1136/bmj.h828).8 However, the challenges that the paediatricians working with Letby faced when reporting concerns, and the experience of other whistleblowers in the NHS, suggest that this isn’t enough (doi:10.1136/bmj.n3147).9 The questionable management of concerns is familiar to NHS staff, says Rammya Mathew (doi:10.1136/bmj.p1966).10 Kirkup and Titcombe call on the NHS to “embrace an open and honest response to any reporting of problems, including by whistleblowers” (doi:10.1136/bmj.p1972).7
While much is said about improving processes for whistleblowers, a “workforce that must resort to whistleblowing is a symptom of poor safety culture,” writes Alison Leary (doi:10.1136/bmj.p1943).6 She suggests that the NHS needs to learn from other safety critical industries and create a culture where there is less need for whistleblowing in the first place.
The Letby case also highlights the limits of a no blame culture, says Mathew: “It’s as though only systems and processes can be criticised, and discussing the possibility of individual accountability is considered ‘off grounds.’” Managers must “ensure that the right actions are taken—not to turn a blind eye because it would look bad,” she adds (doi:10.1136/bmj.p1966).10
Other patient safety investigations found that service managers “put the reputation of their organisation, and by extension themselves, above the need for honesty,” write Kirkup and Titcombe (doi:10.1136/bmj.p1972).7
Is the answer for managers to be regulated like doctors and nurses (doi:10.1136/bmj.m4909)?11 Leary says that without a register of healthcare managers the same problems will persist, with “poor performing leaders [able] to move around the system and even fail upwards into positions of influence” (doi:10.1136/bmj.p1943).6
Although the conduct of managers at the Countess of Chester Hospital has been keenly scrutinised, David Oliver cautions against a polarised narrative of doctors versus managers, which “won’t help resolve many underlying systemic issues in the NHS” (doi:10.1136/bmj.p1957).12
With every patient safety inquiry the lessons are the same. Despite numerous inquiries and familiar concerns raised very little has changed. We owe the families affected by these repeated failures meaningful organisational change. As Helen Salisbury writes, with any service reorganisation the starting point for creating a shared vision of the future is trust and specifically a belief that change has the best interests of patients and staff at its heart. “It will take time, effort, and a lot more transparency to build that trust,” she concludes (doi:10.1136/bmj.p1975).13