Safety Critical Industry - Are you different to the NHS (Lucy Letby)

I was quite shocked in this particular case as I know a very close relative of one of these people who failed in their duty in the above case - I suspect their lives will change and be on 'early retirement' - the cover up is shocking - I'd be surprised if any charges arise, but does Corporate Manslaughter apply in the NHS ?

Have you read Black Box Thinking by Matthew Syed?

It's an interesting read on how the aviation industry has always been open about failures and has learnt from them. It compares the industry to others, notably health, where mistakes are covered up and not acknowledged, making it impossible to learn from them. The case studies in the book may be comparable to recent cases.

In the NHS unlike say air transport critical incidents are seen as reflecting badly on those involved and there is a culture of blame so folk are less likely to whistleblow and more likely to slant evidence

the answer IMO is "no fault" investigations

also the organisation of NHS england lends itself to cover up with the fake competition meaning administrators are reluctant to take action - and can over rule clinicians

Edit: what eck says!

If you look at the named individuals who have alleged failings in this case, then they have moved on several times since Letby was caught and have only gone sideways or upwards. It's not the first time this has been noted, similar things were seen with other NHS scandals, and several of the children's support services scandals.

In my area, if you're ever a named individual in a report, then you're basically a pariah in the industry.

+1 on black box thinking

Culturally, seems like Doctors don't admit to failings anywhere near as much as other organisations - sure they often deal with life and death far more than any other industry, but seem to be too ready to accept "sometimes the patient just dies" as an explanation.

Not every case is a murder, or even a mistake, but should be seen as an opportunity to ask and understand why.

"Sometimes the patient just dies" is often true and and an explanation - but the key thing is they expect to be blamed for honest mistakes so we never get to the truth as they slant their evidence not wanting to be disciplined

My experience is that they are willing to accept mistakes get made and that medicine is inexact - the ethos has changed hugely

Its also true that its never a single failing or action - its almost always multilayered and multifactorial.  In this case other failings are the response of managers at a very supreficial glance.  I'll bet there are staffing issues and management issues on the Ward as well

One problem for the NHS is that admitting to a mistake almost invariably results in lawyers getting involved

I worked in aviation for 30 years & I’m afraid the ‘no blame’ culture isn’t quite as perfectly embedded as the PR would like you to believe 😐

Actually most folk who are involved in medical mistakes merely want to know that it will not happen again rather than being punitive.  Its often only after involving lawyers that families get to find the truth.

I think in this case there’s a significant element of things being obvious in retrospect that weren’t obvious at the time.

The paediatrician who raised concerns I think needs to be careful about what he’s saying.

If he thought from the start that a crime was being committed with children at risk then at that point he should have gone to the police, or at the very least show that he had taken independent medico-legal advice to the contrary.

It seems that it was being treated as a medical malpractice investigation rather than a criminal one, which is a different thing.

some interesting informed letters on this case

https://www.theguardian.com/uk-news/2023/aug/21/nhss-culture-of-denial-allowed-lucy-letby-to-keep-killing-babies

If he thought from the start that a crime was being committed with children at risk then at that point he should have gone to the police, or at the very least show that he had taken independent medico-legal advice to the contrary.

I cant comment directly, but it looks like the doctors followed the correct processes about raising concerns at every point.

Are you suggesting that the doctor should have put their hand in their pocket and paid for medico-legal advice ? That would have cost them 100's of thousands.

Doctors can ask for independent reviews from the relevant regulating body, but that request has to go to their trust, and only the Trust can then request the independent review.  The doctors concerned received written correspondence from senior management telling them to shut up and stop raising concerns.

I think in this case there’s a significant element of things being obvious in retrospect that weren’t obvious at the time.

The paediatrician who raised concerns I think needs to be careful about what he’s saying.

A group of doctors presented data that showed increased incident of mortality, yet the Trust did nothing.

Why does the doctor need to be careful ?

the doctors have a duty to go to the [police if they believe a law has been broken and that confidentiality does not outweigh the broken law that is being reported

I no no other details on this case and its clear they were discouraged at best from doing this but they will have questions to answer.

BMA will provide the advice for free I think

FunkyDunc - I think if you compare to say police, fire service or military failings you will see the same "cover-up culture" - even when stuff has become criminal.

FunkyDunc – I think if you compare to say police, fire service or military failings you will see the same “cover-up culture” – even when stuff has become criminal.

And that is why unfortunately managers do nothing about it, and doctors feel it is not worth trying to do the right thing.   🙁

Obviously what has happened to the babies and their family/friends is awful. But I know that this will have ruined the lives of the doctors involved too. I know with the case much closer to home it has meant many sleepless nights, stress, anxiety, even to the point of thinking taking their own life was a better solution from the way they were being treated purely from raising safety concerns.

I've got Peter Duffy's book, Whistle in the Wind. Was cheap on Kindle

Whistle blowing consultant who left NWEngland NHS to Manx NHS (under IoM control) where he was able to work until his recent retirement

It’s an interesting read on how the aviation industry has always been open about failures and has learnt from them. It compares the industry to others, notably health, where mistakes are covered up and not acknowledged, making it impossible to learn from them. The case studies in the book may be comparable to recent cases.

Safety is one area where commercial aerospace has never competed - it's all essentially open source, fee free patents and (largely) open book lessons learned.

this is the report of a fatal accident inquiry into a preventable death

Yo wuill see the complexities and the multiple errors

You can also see from the full transcript where witnesses under fear of criminal proceeedings slant their evidence so the truth is harder to get to

this case changed practice Sotland wide as lessons were learned

https://www.scotcourts.gov.uk/search-judgments/judgment?id=339d87a6-8980-69d2-b500-ff0000d74aa7

AFAIK, the evidence against Letby is largely circumstantial. The doctors that first raised concerns had pretty much just “she is on duty every time a baby dies” and that was it.

while they clearly took their sweet time, I can see why the trust were reluctant to get the cops involved at first.

Reputational damage was their reason.  a very poor one.  Lots of folk have questions to answer but the senior manager who made the decision not to go to the police is going to have to answer for it.

Its not up to the hospital staff to judge the strength of the evidence - if they think a crime has been committed they have a duty to report it ( so long as its not breaching confidentiality or is serious to warrant a breach)

This duty is actually greater than it would be for a member of public because of the duty of care - and we all have a duty to report potential crimes

Reputational damage was their reason.

It always is. That's the number one driver for most public sector cover-ups.

The NHS has got a long way to go to have a healthy functioning 'Just Culture', it has far too many internal competing interests.

But maybe this could be the incident that is the catalyst for change.

It took 14 people to die in a Nimrod crash to signal the need for change in Military aviation.

Are other industries just as corrupt, or do they have independent regulation that prevents this sort of stuff happening.

They try, or small parts of them do, the penalties are painful. Usually financially.

Just have to look at what happened with Dieselgate.

Or the Ford Explorer Vs Volvo roll over stuff.

Someone i know broke an FAA mandated certification process, one phone call from and all hell broke loose. He'll never work in industry again. Fines were in the millions (For the company), several of his immediate supervisors were sacked.

BMW did a quite minor emissions cheat, that was 20-30 million euros.

Main issue is that it's so hard to find the evidence. Unless they do something stupid.

It always is. That’s the number one driver for most public sector cover-ups.

The NHS has got a long way to go to have a healthy functioning ‘Just Culture’, it has far too many internal competing interests.

But maybe this could be the incident that is the catalyst for change.

It took 14 people to die in a Nimrod crash to signal the need for change in Military aviation.

I'll add, first it's failure to follow the **** process or guidance, then the 'oh shit' moment and furious arse covering.

Not necessarily the same as a serial killer, but anyone involved in Childrens Services will know how close they all are to preventable child deaths, day in, day out, with staff stretched, resources nonexistent and managers stretched and/or powerless.

The the Daily Mail will either crucify the staff for not preventing a death, or for taking someone into care when the parent is adamant they are innocent, depending on the way the wind is blowing.

First of many, perhaps?
BBC News - Alison Kelly: Former nursing manager at Letby hospital suspended
https://www.bbc.co.uk/news/uk-66569258

staff stretched, resources nonexistent and managers stretched and/or powerless.

I think you have to be very careful with that. Can very much sound like excuses and absolves people of responsibility.

indeed.  the thing to do is speak out about the conditions.

Once in my career I raised a safety concern - an acute medical ward was being left with unsafe staffing levels.  I using my code of conduct refused to go home until I deemed it safe.  managers were telling me what I could and couldn't do and saying they had no power to authorise my overtime,  I said to them.  "I am NOT asking your permission, I am telling you what will happen as I follow my legally binding code of conduct"

I was the only person prepared to do this and to poke my head above the parapet.

Banking has changed massively for the better since the introduction of the Senior Managers Regime

Senior managers face fines and jail if they don't do the right thing e.g. PPP mis-selling and the bank gets a massive fine and very intrusive monitoring for years. Amazingly, faced with jail time people take the rules a lot more seriously and make sure their staff do too.

I think something similar could work for NHS senior managers.

Its needs much more and better than a punative approach - it simply does not work as people cover up.

Whats needs is an NHS working collaboratively not fake competitively and a " no blame" safety culture

Its differnt to banking - where these things are deliberate actions in healthcare its mistakes adding up together

indeed. the thing to do is speak out about the conditions.

Moral courage, it's not just a buzzword.

But in defence of some, the conditions/culture in some (many) NHS organisations does not lend itself to a feeling of psychological safety and many choose to look the other way from a self preservation POV.

As you rightly point out it needs a better safety culture, an area I was specifically employed in to support implementation. I have met nothing but resistance from people absolutely unfit to lead others.

I thought after 24 years in the Army I'd seen the worst leadership, some clearly knew that and went "hold my beer..."

<p><span style="font-family: Roboto, 'Helvetica Neue', Arial, 'Noto Sans', sans-serif, -apple-system, BlinkMacSystemFont, 'Segoe UI', 'Apple Color Emoji', 'Segoe UI Emoji', 'Segoe UI Symbol', 'Noto Color Emoji'; font-size: 16px; -webkit-tap-highlight-color: rgba(0, 0, 0, 0); -webkit-text-size-adjust: 100%; background-color: #eeeeee;">This duty is actually greater than it would be for a member of public because of the duty of care – and we all have a duty to report potential crimes<br /></span></p>

<p>but duty of care only unfortunately applies to clinicians. Perversely a Medical Director is actually a management post and absolves them of that duty of care.</p><p> </p><p>The duty of care is one of the reasons why the person I know raised safety concerns </p><p> </p><p> </p>

I have met nothing but resistance from people absolutely unfit to lead others.

Yep that doesn’t sounds like a place I have worked at recently.

If the medical director is still a clinician then they is bound by that  higher duty of care.  As indeed is everyone in the UK - we all have a duty of care to report potential crimes

I have been thru this in much less serious situations with senior management in healthcare.  They found it hard to accept my primary loyalty was to the patents not the organisation and I could legally refuse an instruction from above that conflicted with that duty

but duty of care only unfortunately applies to clinicians. Perversely a Medical Director is actually a management post and absolves them of that duty of care.
The duty of care is one of the reasons why the person I know raised safety concerns

Here a leadership behaviours framework drawn from the organisational values would support.

Apart from.objectives there are very few frameworks which set out explicit behaviours from leaders.

Yeah, three ditty values are great and look ace on PowerPoint slides but do **** all when people are cutting their own detail.

It’s an interesting read on how the aviation industry has always been open about failures and has learnt from them.

im not sure thats always true

https://www.theguardian.com/business/2020/mar/06/boeing-culture-concealment-fatal-737-max-crashes-report

Yeah, I’ve heard some pretty convincing arguments as to why the aeronautical industry doesn’t really bear comparison with healthcare…

I have also worked in a couple of healthcare trust equivalents where there’s been scandals. A paeds Dr that I and many colleagues really thought was great was caught in an international operation. As far as anyone knows it was images only. Very distressing.

im not sure thats always true

It's not. On the whole, better. But not infallible as there are humans throughout the decision making chain.

It's why human factors is so important, irrespective of the industry. The NHS has a long way to go to make any meaningful change in that regard.

The key point is do we want a willingness to report concerns and give accurate evidence?  Thats the only way to prevent further incidents.  If we want those things then "no fault" investigations need to be used.

While people fear disciplinary for reporting errors then its a huge disincentive to reporting

@tjagain have you seen this

A Just Culture Guide

The weakness is it refers to organisational policy & process, which if it's toffee undermines the good that this guide could do. IMO it should be more than a guide, it should be a SOP with trained occurence investigators ascertaining the facts, rather than some midwit from HR.

Have you any idea how many adverse incidents are reported?  NHS lothian was in hundreds of thousands per year IIRC.  My record was putting in 4 on a single shift.  Many of course are insignificant but many are not.

That guide also does not take away the blame culture which needs eliminating

Oh absolutely, I fully agree. The culture won't be fixed by a guide. But without a rigourous framework to follow then you've no hope. As it stands investigations are as competent as those leading them, with methodology hidden from scrutiny until incidents like this happen.

There's an absolute lack of transparency that I'm sure you're more than aware of as a union guy.

Which is why it needs to be a policy and process that is scrutinised as well as all the actions taken by investigators.

I've watched from the sidelines on a recent low-level disciplinary and from an previous experience as an occurrence investigator; supervision perspective this would have been stopped and adjusted. HR were colouring outside the lines.

Since I began my contract all I've heard is ' the blame culture needs to stop' but nobody seems to be willing put their name to decisions that will actually work because it will piss people with influence off.

So when the priority of a board is reputation protection where can the change occur?

we all have a duty of care to report potential crimes

And there's the plaguey rub, what potential crime were they to report in June/July 2015? ALL they had was "Letby is on duty" that's it, that's the sum total of the suspicions, that's not something any one can take to the cops. It's not just the reputation they were concerned with (although the were) , if they'd got it wrong, that people's careers you're **** with, all for a spreadsheet with someones name on it.

A colleague of mine worked with her on a general ward at Chester before she worked in paeds and was interviewed by the cops in 2021 when she was working at my practice. All she could say was she (Letby) was a straight up nurse who asked quite a lot of questions and seemed keen, but didn't really have what it took to be really outstanding, she was to all intents and purposes totally anonymous.

Hindsight's a wonderful thing.

I'm not saying that the Senior management are blameless here, there are clearly questions that needs answering, but it's far from clear that they acted any differently to any other Trust would've done and arguably did better than some have in previous cases. Personally I'd want to see stuff like this handed over to an independent body, but who'd that be I'm not sure, the CQC aren't well regarded by any healthcare institution enough to trust them.

I know I'm going to be crucified but nuclear (in the UK at least) has taken on a lot of open reporting. It's not perfect but at least there is a process and several avenues to resolve an issue before you call a whistle blowing shotline (which we have).

Audit trails for everything too, if you really want to dig down you'll find what you need to.

We know all eyes are on us.

I work in the railway industry.

It took several big crashed that killed and maimed large numbers of people for change to happen.

- Clapham (that had a profound impact on safety in the GB railways, with separate new legislation put in placed following it and the public enquiry (the 'Hidden' report).  But I've held a view for decades that the reason that many safety issues tackled by Hidden still continue innthe NHS as, put simply, Clapham killed 35 in one go, whereas a junior doctor doing a 80 hour week and not enough sleep only kills one person at a time, so their is no hoo-haa and uproar in the press.

There was a massive amount of work done in regards to crash worthiness following Clapham too - the benefits being in design standards for the last couple of decades.

It then took another series of big crashes (Southall killed 6, Ladbroke Grove killed 31, Hatfield killed 4, Potters Bar killed 7) + the public enquiries finally forced other changes, particularly Railtrack went into Administration and came out as a pseudo-Gov body rather than a FTSE100 business.  Legislation also forced fitment of automated safety systems (TPWS) to significantly reduce the risk and probability of a signal being passed when at danger (red)..

When my Father was principle engineer of BAEsystems he put a report into the board, concerning some oil transport tankers. I think possibly for the navy(Who's I couldn't say).

But the issue he had was concerning the formula for superstructure stresses upon launching.

It seems that whoever did them used the formula that is used for aircraft lifting off rather than oil tankers being launched.

The board were not happy, not happy at all as this was a billion £££ contract and I believe they were nearly complete.

He resigned not long after, though I think he was pushed more than anything. I believe he was pretty put out by this, although the managing directer privately said the report was top rate, and he was right to flag it up.

Nuclear bod here too, and we are better than some but it is very dependent on leadership from the likes of the Station Manager.

In a different setting I have done the Public Interest Disclosure thing which did work and stopped a truly stupid and dangerous project, but also revealed how spiteful my then senior management was.

It's all about the people.

“Sometimes the patient just dies” is often true and and an explanation

Maybe, but I think this is where it needs to change. If each death was investigated more deeply along the lines of if we don't know why they died then we had better look into it.

If I was in hospital with a broken leg and I died I wouldn't be happy with a "sometimes the patient just dies" and even if not in the 0.0001% cases where I was murdered by staff it could be a question of malpractice, bad processes etc,. that needs to be investigated. Just as each of the babies deaths.

Need to be careful, that culture of no blame doesn't go too far into one of no accountability. Very rarely do things just go wrong, although medical is, I'm prepared to accept, potentially one where people die 'just because'. In most areas if things go that badly wrong it's because people have done things wrong or badly, and while there may be reasons / mitigation for that such as undertrained or overworked, then the reason doesn't disappear, it shifts. And sometimes systems and procedures are good and appropriate and people just don't follow them. Whether wilful or incompetent, determines the response to some extent, but that can't just be 'ah well, no blame'

I'm not an expert on the case but from the BBC summary I read, there were several occasions where I think this could have been seen and stopped - the evidence was there from the start that these weren't deaths that just happened, eg: frequency of deaths vs historic rate. I understand the concerns that you can't immediately push the big red button and accuse someone of murder, but there was a massive indicator missed in the insulin levels in blood tests from one of the early babies that wasn't highlighted for nearly three years, that if someone had reviewed and looked at properly (done their job properly?) would have created a thread that when pulled would have unravelled the whole thing.

All of the subsequent 'no it can't be' cover ups and obfuscation point to a cultural failure that others have highlighted, and may not have been any different elsewhere as a result. But the evidence was there from the start that these babies had been murdered, and if that had been found then stuff like staff rotas would have led to the culprit easily enough.

Maybe, but I think this is where it needs to change. If each death was investigated more deeply along the lines of if we don’t know why they died then we had better look into it.

Do you realise how many deaths are happening in the NHS each year? - many of which are " expected deaths"  there is a system in place for investigating ie coroners courts or Fatal accident inquirys.  All deaths doctors have to state if its expected or not ( and a second persons opinion is also sought) and if not they will be questioned by the Procutaror fiscal in Scotland and I assume coroners courts.  I have personally had to take questions from the PF over deaths.

The basic issues are IMO

1) Structure in England leading to too much emphasis of protecting the reputation of the hospital

2) a culture of blame whereby every incident people are afraid of disciplinary for  mistakes thus slant their evidence
3) A lack of understanding amongst the public that medicine is an incomplete and inexact science

Interesting Nickc - I of course only have brief reading of the court transcripts to go on but several things she did or said would have immediately raised huge red flags with me

All deaths doctors have to state if its expected or not

These deaths had to be unexpected - 3 in a fortnight, plus the unexpected collapses. How they could have avoided proper scrutiny astounds me (but I'll admit, I'm not a medic or hospital administrator).

And I get that medicine is not exact but presence of large amounts of insulin, without equivalent levels of C-peptide is. Right there apparently, on blood test results. But missed. That takes it beyond conjecture, at that point it is murder and it could have been stopped. Failure to spot that is a major reason why she was able to continue, staff and management could not have ignored or tried to work around that.