The public inquiry into Lucy Letby’s crimes must be widened to examine the NHS’s “cover-up culture” over failures in patient safety, the health service ombudsman has said.
The inquiry should also look into why so many hospital bosses ignore concerns about lapses in safety and victimise whistleblowers who raise them, Rob Behrens told the Guardian.
He wants the inquiry to investigate how the NHS generally deals with failings in care, as well as exploring how Letby was able to murder seven babies and try to kill six others at the Countess of Chester hospital, despite senior doctors raising the alarm about her.
While the inquiry’s first duty is to give the families of Lucy Letby’s victims the answers they want, it should also explore how other hospitals have demonstrated the same “cover-up culture and dismissive attitude” that consultant paediatricians experienced at the Chester hospital, Behrens said.
“We need the inquiry to thoroughly examine NHS leadership, accountability and culture to contextualise what happened.
“Among the many questions the inquiry will need to answer, and without prejudice, is why did the leaders of this trust act in the way they did? And, related to that, why do leaders in the wider NHS too often act in a way that prioritises protecting the reputation of their organisation over patient safety?”
It should also look into why a raft of initiatives in recent years, which were intended to make it easier for staff to raise concerns and to force trusts to be more open about mistakes, have in his view failed to achieve their aims, the ombudsman added. “The whistleblowing law, the duty of candour and the accountability of [NHS trust] boards and executives are not working effectively.”
In 2014 NHS care providers in England were put under a new legal duty of candour. It obliged them to be “open and transparent” with patients about lapses in patient safety and to provide “truthful information and an apology when things go wrong”.
“It is unacceptable that trusts still fail in meeting this duty nearly a decade after it was introduced. The NHS still has a big problem when it comes to being open about patient safety,” added Behrens.
Ministers initially said the Letby inquiry would be non-statutory, which prompted widespread concern that it would not be able to compel witnesses to appear or order the disclosure of documents. Following sustained criticism, Steve Barclay, the health secretary, announced last month that there would be a full statutory public inquiry.
Families of Letby’s victims welcomed the decision. Lady Justice Thirlwall, an appeal court judge, was appointed earlier this month as the head of the inquiry. She is now working with the families to set its terms of reference.
Paul Whiteing, the chief executive of the patient safety charity Action Against Medical Accidents, also urged Barclay to broaden the inquiry’s scope to make it NHS-wide.
Whiteing said: “We need to acknowledge that the issues that have emerged in this case, such as the apparent delays in investigating the adverse trend in the unexplained deaths of babies and clinical staff calling out concerns only to be ignored and made to apologise, are not unique to this trust. It is NHS-wide.”
NHS leaders and ministers should “make the difficult decisions to take a ‘wide-angle lens approach’ to this case and use the sadness of this tragedy to make a step-change to the culture and values of the NHS and ensure openness and transparency are really embedded at every level, from ward to board.”
Whiteing wants Lady Justice Thirlwall to look in particular at how effective NHS trust boards are at exercising scrutiny of and control over the hospital’s executives and who whistleblowers share their concerns with. The inquiry should also investigate whether arrangements governing Freedom to Speak Up Guardians are robust and independent enough, he said. These guardians are supposedly independent senior figures within trusts, often doctors, to whom staff can bring their concerns.
The decision by Hampshire hospitals NHS trust to sack the consultant obstetrician and gynaecologist Dr Martyn Pitman after he aired concern about patient safety failings in its maternity service shows that whistleblowers are still being penalised for speaking out, he said.
Prof Philip Banfield, the leader of the British Medical Association, said: “We receive almost daily feedback that doctors’ concerns are still being ignored and not acted upon because the endemic culture within the NHS is not to want to know what could possibly be wrong. This culture of denial, seen at the highest level … has to stop.”
A Department of Health and Social Care source said the inquiry’s terms of reference are still being drawn up by the judge and families and it could not prejudge them.
