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

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.

Oh I agree – I was talking in general terms about the idea that all deaths need a extra investigation.

The missing of the significance of that blood test is one of the major errors made here.

TJ makes great points.

Also in medicine generally there is an increasing risk of being sued ( in my area for example only Israel has higher rates of attempted negligence claims ) . The consequences of even undeserved criticism and investigation in the form of stress or career / life affecting sanctions don’t really predispose to a culture of openly flagging up personal mistakes. Particularly when from a medical point of view, staffing / time/ financial constraints that are openly acknowledged in real time as added difficulties are often not deemed to be suitable mitigation in hindsight. The level of personal responsibility/ jeopardy that clinicians live with on a daily basis is commonly greater than it is for those working in other industries.

That said, it is staggering how much effort went into ignoring the (7?!) consultants concerns in this Case?

Oh I agree – I was talking in general terms about the idea that all deaths need a extra investigation.

Great, it is a shame I didn’t actually say that all deaths need an extra investigation did I.  All deaths need to be categorized as expected or not and as you state their is a process for that already.

I am saying that process is clearly not working well enough currently, basically what theotherjonv has said

Or the process was not applied?

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

Agreed, and not easily fixed by copying and pasting the same policy used in aviation.

I just heard the interview with Brearey, the Consultant in charge of the neonatal unit where this happened. And I’m uneasy. He’s absolutely right about accountability and the lack of actions by managers / fear of reputational damage which are all right, but he didn’t mention, nor was he questioned on, his own failure to spot and act on the insulin numbers, which surprised me as that was the clear smoking gun.

Sure he asked managers to act ‘on a hunch’ – a very reasonable hunch both at the time and in hindsight – and one that would have put a stop to it. But he seems to be avoiding any responsibility himself.

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.

I disagree, as above there WAS evidence if he/they had read it properly. And on the second point. Tough one this, you can’t be chucking allegations around willy-nilly but (and not necessarily my opinion, but a question for debate) – so if a few incorrect allegations are made and some people have to go through investigation, is that not a better outcome than what happened here? Lesser of two evils?

Really interesting how much effort goes into investigating aviation accidents.

The AAIB have resources to investigate even tiny incidents where the pilot already admitted fault through self -reporting. Just for example: https://www.gov.uk/aaib-reports/aaib-investigation-to-piper-pa-28-161-g-ekir

Government sees fit to allocate resources here, and the AAIB continue to investigate very small accidents with the purpose of publicising them to inform aviators as well as issuing specific safety notices through the CAA.

It may not be perfect, but it is a pole apart from healthcare. And a key tenet is the reporting culture, from self-reporting to anonymous reporting by concerned parties. Allocating resources to a reporting line would appear to be a decent first step for the NHS.

Listening to Dr Brearey this morning (he was one of the Letby consultants), it was obvious that he couldn’t articulate or even imagine a whistleblowing culture.

Why didn’t the consultants complain outside the Trust to their union, the nursing union, the CQC, NHS England, the HSE etc? The doctor just didn’t see beyond the Trust. The reporting framework just does not exist, or if it does no-one knows about it at the Countess of Chester.

There does need to be a sea-change in British healthcare if lessons are truly to be learned.

My industry (Pharma) is highly regulated, my work scrutinised appropriately and all is trackable and inspected by agencies. There have been thankfully very few incidents (Northwick Park for TGN1412, and Bial for the FAAH inhibitor) in early clinical trials, and these have led to careful consideration of improvements (I wrote the dose rationale for the Duff report appendix for TGN1412). I would, however remind people that regulators might not be the absolute experts in a field; TGN1412 was approved for dosing by both the MHRA and the German BfArM agencies. I would have no issues raising concerns regarding safety.

I am required by policy to report via our own internal systems ANY adverse events I ever hear of for any of our medicines taken by people who tell me they’ve had one. That’s on top of any public reporting (yellow card for example).

It may not be perfect, but it is a pole apart from healthcare. And a key tenet is the reporting culture, from self-reporting to anonymous reporting by concerned parties. Allocating resources to a reporting line would appear to be a decent first step for the NHS.

There are two parallel reporting options in NHS Scotland.  Datix system and whistleblowing system..

I have to be careful what I write here.  My wife works directly in line of one of the senior leaders who has recently been suspended (albeit it from a new role in a different trust.). This individual (now all over the news) was suspended from her current role, though it was kept very quiet internally (hardly anybody knew until last week) and my wife knows her reasonably well in a professional capacity. OH was called into a meeting for senior management at her trust yesterday to be briefed about events.  She came home last night and was totally shocked as the tone of the briefing; it was very much sympathy with the individual and how much of a hardship it was for her, with a lot of agreement in the room. My OH assessment was of that senior management briefing, 75-80% had a nursing background (my wife has an AHCP background) and the mood and tone was very much sympathetic and almost closing ranks within the profession with use of emotive language such as ‘witch-hunt’ etc.  Quite frankly I was appalled.  I woke up still thinking about the situation this morning and am fearful for how successful the public enquiry might actually be.

People who raise concerns and speak out against issues are not typically the people who climb career ladders into senior leadership roles.

Board rooms are filled with people who rely on the status quo, because that is what got them there.

So the further up a ladder you look, the more wilful ignorance you will see.

It’s the way most things get built. People patting themselves on the back until the pile of bodies gets too big to ignore.

And we wonder why our world is burning.

I’m oil and gas and to be honest I’ve been pretty disappointed by the dealings I’ve had with the  regulators that we have. If you are looking to a third party make sure your house is in order then you’re in for a let down.  Perhaps I’m just jaded.

I find the whole reporting of this tragic case a good example of miss direction for the following reasons some of which might be with the benefit of hindsight

1. if the consultant was concerned why were no autopsies ordered by the consultant to confirm that cause of death was at least consistent with the condition the babies were being treated for?

2. All this talk of blaming managers fails to point out that the medical director is a consultant. The director of nursing is a nurse. The deputy chief exec in this case is also a doctor. So the responsible management are in fact all clinicians and not faceless career managers who dont know one end of a thermometer from the other a sis being portrayed.

3. if the consultant had such concerns why did he not formally whistleblow to the independent body that investigates this or report his concerns to the GMC?

There are two parallel reporting options in NHS

Then why were they not used? That’s the cultural point. The consultant failed to do anything than to report to the trust.

Datix is an internal system but its not one that can be ignored.  I do not know what the English equivelents are.

Stingermered

I see no reason why that Senior nurse has been singled out for suspension?  And as soon as I saw it I thought – its the old pass the blame and try to find a scapegoat going on (which is often a nurse) – and those senior nurses has very little actual power compared to the medical director and the trust managment

No, nobody knows exactly why at the min but… that person was director of nursing at the time and apparently*  suspicions were raised to them and did not act on them. Not investigated and concluded ‘no issue’ but did not act.

*tbc by enquiry, (or not.)

@FunkyDunc

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

That’s what I’m questioning. I think that they followed it correctly for a clinical governance problem, but at least one of the doctors seem to be saying that they knew from an early stage that it wasn’t a clinical governance problem, in which case I’m not so sure that they have. That’s why I’m saying that I think they need to be careful about what they’re saying.

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.

All doctors in the UK have access to independent medico-legal advice as a condition of being a registered medical practitioner.

If something like this happened to me, ie I had suspicions that someone was deliberately harming children, and my superiors weren’t acting on it, I’d be straight on the free independent medico-legal advice line.

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

Didn’t the trust commission two independent external reviews?

Didn’t the trust commission two independent external reviews?

yes – but with very limited remits that showed no concerns – because they didn’t look for them is my understanding

No, nobody knows exactly why at the min but… that person was director of nursing at the time and apparently*  suspicions were raised to them and did not act on them. Not investigated and concluded ‘no issue’ but did not act.

I remember reading that the head of the neonatal unit had reported his concerns about Letby to the head of nursing, was basically ignored and she was allowed to continue working there. Even at the time I thought it was odd that the person in charge of the whole department could be overruled by the head of nursing, even if he thought it was a competence problem and not actual murders. I also wondered if he was trying to cover up how little he’d done, but more info has been released since then.

(Sorry about the vagueness, it’s a while since I read it and it was only on BBC or similar, so I partly assumed that it was poor reporting.)

Datix is an internal system but its not one that can be ignored. I do not know what the English equivelents are.

Datix is the English equivalent

@tjagain, but that’s my point.

The reviews were looking to see if there was evidence of clinical incompetence not a murderer.

That’s not unreasonable. Medical murderers are fortunately rare. Clinical incompetence unfortunately is not.

Looking for clinical incompetence is not the same as looking for evidence of crime, so it’s not surprising that the reviews didn’t turn anything up.

But it’s not doing nothing.

I think the reviews were deliberately designed to show nothing myself – I think the ass covering had already started then.  those reviews should have flagged up that insulin result?

 those reviews should have flagged up that insulin result?

Not an expert, only a GP, but they wouldn’t necessarily if they weren’t suspecting foul play.

We are really speculating from here.  IMO those reviews were intended to give a negative result.

Not an expert, only a GP, but they wouldn’t necessarily if they weren’t suspecting foul play.

But there was already a suspicion, and even if foul play itself wasn’t suspected at that point then the case rate and near-misses suddenly increasing that much means there should have been. Why are babies suddenly dying at this rate, what do we know about them? Even if foul play wasn’t suspected competence should have been and someone should have looked at their notes and blood test results and had a ‘hang on’ moment.

But they didn’t.

The management could not have ignored that. The babies died because LL was giving them insulin, everything else follows from the fact that this was ‘known’ (as in documented on blood test results) but not acted upon.

If something like this happened to me, ie I had suspicions that someone was deliberately harming children, and my superiors weren’t acting on it, I’d be straight on the free independent medico-legal advice line.

Where does this free medico-legal advice come from ? As I have said in my initial thread, I know someone who is going through almost identical scenario (apart from the level of harm is not as severe) Their medical union has refused to give them legal representation.

Didn’t the trust commission two independent external reviews?

None of us know exactly what happened in this case, but I understand that doctors requested an independent review and this was turned down by the Trust ( a royal college review can be called for by a doc, but the Trust has to agree and request it.)

Maybe 2 ‘independent’ external reviews were requested, but thats the issue. They are commissioned by the Trust and will always be biased to what the Trust wants to hear as they are paying for it.

Again the person I know who called for an independent Royal College review. The Trust refused and commissioned an ‘independent’ review which ignored all the data, didnt interview the relevant people, and came to a conclusion that the people raising concerns needed to just shut up and re build relationships.  Not long after an email came from the Medical Director telling them to draw a line under their concerns and shut up.

Re Datix – My ‘friend’ was told to stop reporting incidents on Datix, and if they continued to report safety concerns about an individual, then Datix would be removed from them.

Re Datix – My ‘friend’ was told to stop reporting incidents on Datix, and if they continued to report safety concerns about an individual, then Datix would be removed from them.

Thats back to culture and would be very dodgy indeed.  I used to drive my bosses mad with Datix reports – a couple of times I got asked to stop doing so and simply quoted the NMC at them and refused to stop.

Thats back to culture and would be very dodgy indeed

Yeah but even the Letby case is about culture. I bet they had all the frameworks and SOP’s in place, but it makes no difference if people in power do not want to play by the rules.