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

Depends on the failing.  A punative approach does not work.  To continue to do the same thing and expect a different outcome?

the failing may require nothing, it may require retraining, if a criminal threshold is reached then obviously prosecution

what should not happen is honest mistakes leading to disciplinary

Doesn’t have to be criminal, in the (hypothetical I must stress!) example above no law was broken – although technically the HSE could contest that in the serious cases – but clear policies and practices were. And there’s a grey area between wilful and pure accident where many other factors come in – including competence and training, etc.

Honestly, you don’t need training or competence to be able to have a window open on your PC where you can see a co-worker. You don’t need to be trained to be told not to wander off and forget you were doing it when someone at the kitchen distracts you. At no point did they go ‘I know I’m supposed to be keeping watch on Dave but **** it, I’m going to talk to Simon about the football’

But it’s not ‘an accident’ either – and to not allow John to get an appropriate telling off for not doing his job properly – would he do it differently next time? I bloody hope so.

Here a comparison of two different approaches. For balance:

The Military Aviation model:

The NHS Model:

One of these is a guide that lacks any conversation about culpability and leaves that in the hands of HR, the other a mandated, transparent, and assured process that shares findings widely.

Which would give you more confidence in being open and honest?

theotherjonv

I would say in the case you mention its a training / competency issue not disciplinary and should be dealt with as such

Really? You’re talking of the watcher, not the actual experimenter? How much training / competence do you need to understand how the virtual buddying system works……. keep an eye on Dave to make sure they don’t hurt themselves.

The experimenter – I’m quite low on sympathy for. If I put that through the flowcharts above I’d get to (MOD) rule breaking for selfish (their own time) gain, or organisational gain (possibly…..although any time saved for the benefit of the org would be lost 10x over in the clear up)

or via the NHS one – kicks right at foresight test: singling out individual unlikely to be appropriate (agree, but a lessons learned for the Org would be) – and actions for the individual (but as R-M has said, unclear from that what they might be). They don’t need training, other than training to know not to break the rules in place for their safety!

Someone who failed to do their job in 2015 is unlikely to have changed their behaviour.

Depends – possibly culture has changed in the admin management area, possibly not, but if any of them reflect and think they got it right and they’d do it all again then I don’t know what to think.

And the clinical management – I think they too would have to reflect. Seems to me (and I know I’m not an inquest and not in possession of all facts) that there was hard evidence in the form of eg: Insulin levels from pretty early on that they didn’t read or take note of. I’d also reflect that the lab tech who ran the bloods could / should have spotted high levels and flagged, or if they are simply churning out results by pressing buttons that the computer could easily be updated to flag if the insulin is synthetic (absence of the co-factor)

The Provider/Purchaser split was a disaster from the get go (Landsley 2012)  I don’t think there’s been legislation to actually take it off the the statue, but Stevens in 2017, and the long term plan in 2019 pretty much killed it. The only thing left is NHS Property I think

The NHS internal market is very much alive and well along with the provider / purchaser split. All that has happened is that ICBs now commission, rather than CCGs and PCTs before them (which look remarkably similar to PCTs). There is still a price list for everything https://www.england.nhs.uk/pay-syst/nhs-payment-scheme/

Turns out I was wrong about my consultant colleagues having access to independent medico-legal advice, some may do, but it’s not mandatory for them to have it, unlike us GPs.

https://www.bbc.co.uk/news/uk-england-merseyside-67006930

Lucy Letby: Corporate manslaughter probe at Chester hospital

I am not sure what ‘Corporate Manslaughter’ is ie what the test is. Hopefully might be the kick up the arse hospital management need

Unfortunately my experience of the threat of corporate manslaughter is that managers are so shit scared of it they spend an inordinate amount of time making sure that individual employees will get the blame should anything happen. (Rather than making sure it doesn’t happen in the first place)

I am not sure what ‘Corporate Manslaughter’ is ie what the test is.

it needs to be a relevant organisation (nhs trusts seem to qualify) it needs to have a clear duty of care (that would be hard to argue against) and there has to have been a failing in that duty so serious that it merits criminality.  Those are my words not the legislation.  interestingly there’s no need to the organisation to have had foresight that death might result so on paper it seems easier to prosecute but I think it’s exceptionally rarely used because it is very hard to prove.  I’ve heard enough to know why they are pursuing this – but I think it’s far from certain it will succeed if the trust pleads not guilty – all they need to do is cast doubt that as an organisation they acted as best they could and were getting advice from some of their more junior managers that all was ok and I think they may have a defence because it’s only the actions/inaction of the most senior managers or the organisations wider systems that fall under corporate manslaughter.

Hopefully might be the kick up the arse hospital management need

unfortunately I won’t – the result of corporate rather than “personal” manslaughter is that the trust not the individuals will get a massive fine.  Likely if there is a conviction the judge ends up limiting the fine as it only hurts patients.  The kick they need is personal liability for their failings; although I suspect that will make many, more reluctant to make decisions and life harder for people in the nhs rather than recognising that it was about bad people not doing the basics right.

I nearly gave expert witness evidence at a corporate manslaughter case, until the defence understood what I was likely to say and that it would likely be more beneficial to the prosecutor.  That case took 6 or 7 years to get before the courts and the crown backed down at the 11th hour and accepted a much less serious H&SAW act charge.  Having seen the evidence – it looked like a straightforward case – the company was at fault, but the issue was how high up the tree could they show involvement in the decision making and that it was not a “rogue employee” ignoring policy. (My evidence was not relevant to that but would have been an attempt by the defendant to suggest they perhaps didn’t cause the death at all).

All the management should have the same professional acountability as doctors and nurses and the same legal obligations.   It concentrates the mind knowing you could be answerable in court.

Criminal charges are exactly the opposite of a culture of safety.

So is “accountability”.

A culture of safety is one in which people are encouraged to acknowledge and share their mistakes for the benefit of the organisation.

Threatening them doesn’t make this happen.

Correct Kramer

However its also right that you should be able to be called to explain your actions in a coroners court or similar forum.  The threat of criminal sanctions should not be there unless you are not truthful or your behaviour was deliberate or malicious.  There should be no criminal sanction for honest mistakes.

  It concentrates the mind knowing you could be answerable in court.

it might very well do, but given the amount of clear malpractice that the indemnity unions defend every year, I don’t think it’s making much difference.

A culture of safety is one in which people are encouraged to acknowledge and share their mistakes for the benefit of the organisation

But Letby was deliberately malevolent, it has nothing to do with mistakes that the unit made, so then you look to the mistakes that the upper management made.  To me it’s clear only with the benefit of hindsight that the management of this hospital made the wrong call not to involve the police earlier, but you can see the perfectly reasonable steps they took to arrive at that decision, and in all of these types of cases, some of time, the wrong decision is going to be made, and it’ll happen again. Because like this case, that you have a serial killer working at your hospital is rarely going to be the first and correct decision you arrive at when there are unexpected deaths on a ward..

wrong thread ignore me.

in the Letby case there are still ( with hindsight) clear errors on a number of peoples parts. 

If we want to stop errors happening and to do so we require candour.  If people are afraid of being blamed and criminal sanctions then we will not get candour

If we want to stop errors happening and to do so we require candour.

I don’t disagree, but “We appear to have employed a serial killer” category error seems so wildly outside the normal operational decisions that any Trust senior executives are qualified to make, do we really need to broaden the definition of the corporate manslaughter rules that members of the Trust’s executive are being investigated under now? If it gets to trail they’ll be required to swear on oath anyway.

If people are afraid of being blamed and criminal sanctions then we will not get candour

Agreed ish – but if people behaved we wouldnt need prisons. Also in other places in this thread, the NHS doesnt allow people to raise concerns unfortunately is culturally systemic in the NHS to not allow people to raise issues of safety

Way outside my sphere of knowledge, but if an organisations fails to correct Health & Safety stuff in the workplace, can they not get criminally prosecuted ?

Is this any different? The management did put due process in place/follow it to prevent patient harm ?

serial killer

@nickc and that’s the key point. Most healthy safety cultures use a test of reasonableness or what other trained a competent people might do.

She is an outlier because she was malevolent. The danger in this situations is people either assume malice across the entire spectrum of the incident, or in this case infer that others had the same level of malice.

It’s emotive because it’s babies, understandably so. But it’s the emotions that run the whole thing off the tracks.

The point about criminality, excluding Letby for now in a more general POV, unless it is glaringly obvious or evidence has been presented of clear criminality then there’s little purpose in using it as a threat at the outset. It’s been proven to harm the quality of investigations outside of the CJS.

Most investigations I’ve seen in the NHS thus far aren’t truly independent, allowing the facts to inform the outcome. They have been trying to prove the accusation or failing, to gather evidence to support the “problem”.

Case in point, evey person I spoke to in a recent piece of work (55) at the outset of an investigation had been presented a document outlining the process of the investigation and disciplinary process, along with the sanction guidance (which is policy).

No facts have been gathered, nothing has been proven or disproven, but we’re subjecting individuals to a CPS-lite procedure from the outset and wondering why the culture is poor? It’s a culture based on fear of subjective judgement and punishment.

A just and blame free investigation and culture does not mean no accountability or sanctions, it means impartiality until the facts are gathered and an evidence led outcome is decided. That outcome might be referral for criminal proceedings.

The fact that there is pushback against this sort of approach and complaints about the blame/cover-up culture in the same breath would be hilarious if it wasn’t tragic and somewhat ridiculous.

“Do what you’ve always done, get what you’ve always got” springs to mind.

Also I don’t hold the NHS fully to blame for this. The CIPD and HR culture and training have a lot to answer for. They’re the biggest threat to culture change within this complex organisation in this regard.

It’s not really a case of ‘I told you so’ but I’ve always had my doubts about the Lucy Letby trial, and her guilt. As much (if not all) the evidence against her was circumstantial. Private Eye have conducted an investigation, and published their findings – after over turning a court application to stop publication.

Makes for interesting reading 

I haven’t read a lot of the detail but two things come to mind.  1) some of the evidence against Letby is flawed to say thew least

2) I still believe she did it.  Her behaviour was so weird and the weight of evidence even without the dubious stuff so strong

and the weight of evidence even without the dubious stuff so strong

Read the P-E stuff and see if you still think that. I’ve (like you) always assumed that there must be more to it than the flimsy circumstantial evidence, but it turns out that the defence didn’t call any of its expert witnesses who have told a quite different story to the one heard at trial. While obviously its up to the prosecution to prove guilt, not for the defence to prove innocence, it does mean that the jury essentially got hear just one side.

It’s possible she did something but also appears undeniable that the case was horribly flawed and there has been a gross miscarriage of justice along the lines of the cot death fiasco a while back.

David Allen Green has misgivings on how the trial was conducted. No answers to an awful lot of questions here

Lucy Letby and miscarriages of justice: some words of caution on why we should always be alert to the possibilities of miscarriages of justice

It seems to imply a lack of statistics knowledge by the legal system in general.

Just read the Private Eye report. Holy shit. I had no idea that it was a conscious choice on the part of her defence not to introduce experts to cast doubt on the clinical evidence the prosecution was putting forward. I just thought it was because no  rational counter-argument could be made along those lines. Presented like that, the case looks paper-thin.

The parallels with the Bristol Heart Baby case, which I know well, are very clear. Obviously in that case the surgeons involved made the case that there were other similar reasons for the increase in their mortality rates – sicker babies, etc, but were struck off mainly because in their overseeing capacity they should have stopped operating sooner once the spike became apparent.

Not so much the physical evidence as her behaviour.  If I had seen her behaviour as a nurse I would have been very suspicious indeed and would have reported her.  some of the things she did are so far from acceptable in nursing its not true.  Some of them are instant dismissal offences

The way the Eye presents it almost makes it look as if they’ve tried to retrofit murder to explain a spike in infant mortality at the unit. When there are many complex alternative reasons why a particular unit might be performing so badly. I must admit I didn’t follow the published trial evidence closely, found it a bit too distressing at the time.

There are plenty of nurses out there who are bad at their jobs and perhaps even should be dismissed/struck off for their behaviour. I’m now left very uneasy about the weight of the evidence taking her from being incompetent or weird/inappropriate to being a remorseless, calculating and precise serial killer.

I have never seen a nurse behave as bizarrely as she did.  I have met inadequate nurses and weird ones but never anyone who did stuff like she did.  Taking photos of babies?  Instant dismissal and totally bizzare.  Taking notes home?  Instant dismissal etc etc.

She is not a calculating and precise serial killer.  She is mentally severely unwell.  Her actions cannot be explained in any rational way.

this was not just a spike in deaths – someone was killing these babies.

Not so much the physical evidence as her behaviour.

Doesn’t make her guilty though does it? I mean sure you might be suspicious, but the only evidence is the excel with her name on it, there was no investigation at the trial about how accurate it was, or where the data had come from. One statistical expert has called it “Evidence that Letby was on duty when she was on duty”

his was not just a spike in deaths – someone was killing these babies.

Several paediatric experts (some of them defence expert witnesses who weren’t called ) disagree with that assumption. These babies were often presented to the jury as ‘well’ when they were in fact very far from being well.

I haven’t had a chance to read everything properly yet (and honestly, most likely I won’t) but is there any explanation given about why the defense didn’t call their expert witnesses?

The spike in deaths: And that is what the statisticians have since identified as misleading. The statistics presented to show bias to those who do not understand them.

She deserves another trial where all evidence is clearly scrutinised – its horrendous if she is innocent – as is its horrendous if she is guilty. Those babies and their families deserve to know the truth .. not just have a scapegoat.

He defense team appear to be shite for sure.

there is a lot more good evidence than that nickc.  Like the consultant that walked in on her with a baby thats breathing tube was dislodged and the alarms turned off and letby just standing there watching the baby die.  that has no innocent explanation.  It is inconceivable she did not know what was hapening

Whether there is enough good evidence to convict I am not sure.  However I am sure she killed those babies

but is there any explanation given about why the defense didn’t call their expert witnesses?

From the private Eye investigation report:

Letby and her barrister Ben Myers KC did not call their single expert witness to give evidence, secure in the knowledge that the evidence against her was largely circumstantial, and perhaps mindful that the prosecution had six expert witnesses and seven consultant paediatricians who were united in believing her to be guilty because it seemed the most plausible explanation for the spate of sudden and unexplained collapses.

However I am sure she killed those babies

I’m not sure she did, but I think it’s pretty certain that either way, the jury did not get to hear the full scientific or statistical evidence.

It’s possible she killed and harmed some, but wholly implausible that she did all of them. Ergo, miscarriage of justice.

And being weird and worthy of instant dismissal isn’t the same thing as being a mass baby murderer.

Else where are Liz Truss’ victims hidden (etc etc)?

Whether there is enough good evidence to convict I am not sure.  However I am sure she killed those babies

There was enough evidence to convict, and the jurors were sufficiently sure to do it. Whether the prosecution evidence was sufficiently challenged in court – and whether her trial was unfair as a result – is the question here.

If a fresh jury are presented with the same evidence – and perhaps a more robust defence involving expert witnesses pointing out some of its flaws and inconsistencies – and they still choose to convict, so be it.

Whether there is enough good evidence to convict I am not sure.

Not very well put.   Sorry.  Of course I meant was the evidence robust enough to convict given a competent defense which Letby did not appear to get

. I must admit I didn’t follow the published trial evidence closely, found it a bit too distressing at the time.

I followed it reasonably closely at the time. I was called for jury service at Manchester CC and swerved serving on the Letby case by inches, I had to explain to the judge that I worked with a potential witness who was a Doctor on a general ward who’d worked with Letby before she transferred to neo-natal. If called she was going to say that Letby was OK, just a nice normal nurse, a bit slow, never really outstanding, but reasonably competent and capable.

but reasonably competent and capable.

Which makes the doing nothing with a baby dying from a dislodged ET tube and with the alarms turned of even more damning.  there is just no way on earth that is not malicious

The fact is, we are now being given a barrage of defence ‘evidence’ which hasn’t been tested in court. Personally I’m going to stick to the opinion that she received a fair trial and a jury, which was presented with all the evidence the defence thought appropriate, convicted her. I’m saying ‘Guilty as charged’. I’ll wait until the outcome of any subsequent legal process before posibly changing my mind.

Also, from the BBC:

Barrister Tim Owen KC has spent 40 years as a defence lawyer, and worked on many cases which he successfully referred back to the Court of Appeal and the Criminal Cases Review Commission.

He also co-hosts a legal podcast, Double Jeopardy, which has examined the Letby debate.

Much has been made of the fact that the Letby case relied on circumstantial evidence and no-one definitively saw her harming any of the babies.

Mr Owen said this point is far less relevant than many might think.

“Some people believe that circumstantial evidence isn’t really evidence,” he said.

“That’s simply not true.

“A circumstantial case can be a powerful case but in order to understand it, you have to look at the totality.

“You can’t just pick one little bit and say, ‘Oh look at that, that’s unreliable,’ or ‘That doesn’t prove anything’.”

there is just no way on earth that is not malicious

Unless she’s stood there thinking “oh no, how can this be happening again”

I dunno, I wasn’t there. Neither was anyone else.

There were other excess baby deaths when she was not on shift that were batted away as irrelevant. It looks dodgy.

I assumed she was a monster, having read the PE series it’s not so clear cut.