‘The message from this case should be loud and clear, listen to clinicians’

But it was in 2018 that the woman held on suspicion of murdering eight babies at the Countess of Chester Hospital was identified as children’s nurse Lucy Letby, then aged 28.

“I feel the message will be loud and clear on one thing. Listen to clinicians”

And the deaths and non-fatal collapses at the hospital’s neonatal unit involved in the case occurred back in 2015 and July 2016, eight years ago or more.

The details of this case are truly horrible and, as chief nursing officer for England Dame Ruth May said today, will leave nurses “sickened”. I will not, therefore, repeat them here again.

However, what has come through strongly from the case is that, unusual as it was, it was another example of trust managers failing to take due notice of the views of clinicians.

It was in late June 2015 that the neonatal unit’s head consultant had mentioned to senior management that Letby had been present when the baby collapses took place.

The court heard that concerns among consultants then increased and were voiced to hospital managers when more unexplained and unusual collapses followed.

However, in spite of these concerns, Letby was not removed from the unit until two further deaths and a collapse happened.

She was then confined to clerical work but in September of 2016 registered a grievance procedure, which was apparently resolved in her favour in December, it emerged during the trial.

Letby was in fact due to return to the neonatal unit in March 2017, but the move did not take place because soon after police were contacted by the trust and she was ultimately arrested in July 2018.

These revelations today were sufficient to move the parliamentary and health service ombudsman, Rob Behrens, to question “culture and leadership across the NHS”.

He called for “significant” improvements to both so the voices of staff and patients were heard, with “regard to everyday pressures and mistakes and, exceptionally, when there are warnings of real evil”.

The ombudsman noted that, throughout the trial, there was evidence that clinicians “repeatedly raised concerns and called for action”. “It seems that nobody listened and nothing happened.”

“Those who lost their children deserve to know whether Letby could have been stopped and how it was that doctors were not listened to and their concerns not addressed for so long.”

The government has duly announced an independent inquiry into the circumstances behind Lucy Letby’s crimes.

A key part of its remit, as indicated by the Department of Health and Social Care this afternoon, will be to look at how the concerns raised by clinicians were dealt with.

I can’t help feeling that its recommendations, when they emerge in however many years’ time, will be remarkably similar to what the ombudsman has already said today.

Some of them will surely have echoes of previous inquiries into unnecessary patient deaths, which were either the result of accident, negligence or design.

I am minded, once again, of the two Francis inquiries into Mid Staffs, which identified a culture in which staff members who had concerns about failures in care were discouraged from speaking out.

The 2015 Kirkup inquiry into Morecambe Bay, meanwhile, found missed opportunities at every level of the organisation to intervene in the maternity care failings that occurred there.

Going even farther back, the Kennedy report into high rates of baby deaths after cardiac surgery at Bristol Royal Infirmary during the 1990s found problems around culture and leadership.

That report concluded in 2001 that there was a “lax approach to safety, secrecy about doctors’ performance and a lack of monitoring by management”.

Once again, culture and leadership in the health service is in the spotlight. Opportunities to save lives were seemingly missed due to inaction.

The inquiry will do doubt make a range of sound recommendations on different aspects of the case. However, I feel the message will be loud and clear on one thing. Listen to clinicians.