Lucy Letby: the NHS needs to undergo a culture change

Calls for more powers for the independent inquiry into the Lucy Letby murders should be taken seriously. The inquiry must have the confidence of the public. But such calls are also partly symbolic. They are a way of expressing horror at such transgressive behaviour, and of demanding that the most strenuous efforts are made to avoid such terrible killings in future.

Steve Barclay, the health secretary, has set up an independent inquiry. However, it does not have full statutory powers, which may make it easier for managers at the Countess of Chester Hospital at the time of the murders to avoid giving evidence. Plainly, if there is any sign of this happening, the remit of the inquiry should be looked at again, but there are good reasons for avoiding the cumbersome bureaucracy of the Inquiries Act.

And, while the inquiry is important, it is not necessarily the most important part of preventing cases such as Letby’s happening again. It may shed some useful light on the psychology of someone such as Letby abusing their power, which was discussed in court but not in any depth, and on the attitudes of those in positions of responsibility that prevented early warnings from being acted on.

This may help inform the three parts of what needs to be done: better screening of personality types; better monitoring of care; and better responses to warning signs.

But the important part of learning the lessons is what happens in the NHS. It is a question of understanding how to change the culture of large organisations, which requires leadership, both at the political level and at the level of senior NHS administration.

Mr Barclay needs to convince the public and NHS staff that he cares about patient safety and is doing something about it. He should perhaps take a leaf out of Jeremy Hunt’s book, and emulate some of the good things that his predecessor did as health secretary. Mr Hunt’s record was not perfect, but he had to deal with some terrible institutional failings. He dissolved the Mid Staffordshire NHS Trust after appalling standards of care and high mortality rates were exposed. He worked on learning lessons from the airline industry – rigorous checklist protocols and quick no-fault investigations – and even wrote a book on the subject, Zero: Eliminating unnecessary deaths in a post-pandemic NHS.

Mr Barclay must find and promote NHS leaders who are committed to extending these lessons to all parts of the service. Above all, that means changing the incentives that act on hospital managers. In Letby’s case, doctors noticed that the nurse was present for the unexpected deaths of three babies in just two weeks, and raised the alarm. Yet she was allowed to work at the unit for a further 12 months, because of “hospital managers seemingly prioritising the hospital’s reputation above child safety”, as lawyers for some of the parents put it. Ravi Jayaram, a senior doctor, claimed he was persuaded not to contact the police because it would harm the hospital’s reputation.

This needs to be turned on its head throughout the NHS: individual managers should be rewarded for acting quickly and openly on concerns, and units and trusts should pride themselves on a safety-first culture.

Whatever the inquiry finds, and whatever powers it has, that work should intensify now.