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

The news is currently full of the Lucy Letby case, and how she managed to kill so many babies.

Thankfully questions are being asked about how it was allowed to happen, and it is clear that the NHS Management Team of the Trust clearly has been implicated as being complicit in trying to ignore the situation / high levels of incompetence, and at worst guilty of Corporate Manslaughter.

When the case first came out in the news, I was shocked to find that nearly every circumstance that the doctors had gone through, someone much closer to to myself had gone through almost identical process. ie raising safety concerns, safety concerns being ignored, request to independent report refused, senior managers telling clinicians to draw a line under their accusations, grievances being lodge against those raising concerns.

I have also worked in Trusts before where a surgeons outcomes were known to be bad, even to the extent of deaths having to go to Coroners Court for any action to be taken, then for the surgeon to be paid off and now earning even more money privately in Dubai. I know of one Chief Exec who was forced to resign as he tried to cover up the fact that a body was ‘put in a cupboard’ for a couple of days. He was then placed at a different NSH Trust, and there was no update to process

Maternity scandals in the NHS are the result (in many cases) of people not taking safety seriously. Jimmy Saville was allowed to continue despite many people raising concerns.

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

In the NHS the most positive action appears to be that senior managers go off ‘sick’ followed later by they have now left the Trust, only to pop up in another Trust in another part of the country. Senior central NHS management appears to manage this process !

I work in the NHS and I feel embarrassed and ashamed that this sort of stuff goes on, but I have no idea how you would go about solving it as the culture of sweep it under the carpet because we know we have poor process appears to be so prevalent.

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</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