August 23, 2023

A sense of catharsis seemed to envelop Britain when it was announced that Lucy Letby had been handed a life sentence for her crimes. The appalling 10-month litany of her homicidal activities was over. Evil had been exposed. Justice had been served. Perhaps, now, we could all move on.

To feel relief, though, is surely misguided. Nurse Letby might be behind bars, but those who ignored, shielded or enabled her remain unpunished. Regardless of their motives or excuses: the public record has shown that senior executives at the Countess of Chester Hospital obfuscated attempts to stop Letby.


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This is not to say they aided and abetted her. But as any lawyer will tell you, ignorance is no defence in law. On the wards, as anywhere else, those who want the benefits, privileges and status that come with the highest level of leadership must shoulder responsibility for what happens on their watch.

Following Letby’s conviction, the Northern Care Alliance NHS Trust in Greater Manchester suspended Alison Kelly, former director of nursing and quality at the Countess of Chester. The hospital’s former CEO, Tony Chambers, also faces mounting claims that he had dismissed warnings about Letby before walking away with a £1.5 million pension.

Under Kelly and Chamber’s leadership, the neonatal unit’s head consultant, Dr Stephen Brearey, who first raised concerns in June 2015 about the link between Letby and an increase in baby collapses, was ignored. Likewise, Dr Ravi Jayaram, a consultant paediatrician at the hospital, and others, were forced by hospital bosses to apologise to Letby after was “upset” by their criticisms of her.

We don’t know what Kelly and Chambers were thinking as they watched a significant rise in the number of babies suffering serious and unexpected collapses in the hospital’s neonatal unit from 2015 and 2016 — a rise that was well above the expected local average. We do know that they failed to act decisively. We also know that they both objected  to concerns raised by Breary, Jayaram and other clinicians. These “whistleblowers” were told there was “no evidence” against the nurse “other than a coincidence”.

In my experience, such negligence can be partly the result of the professional differences — and hostilities — between those from a nursing or midwifery background and doctors and senior consultants. When doctors raise concerns about nurses, the nurses’ ranks tighten. When the roles are reversed, however, doctors are far less likely to put professional favouritism first.

And this conflict particularly afflicts maternity wards. As I warned in UnHerd last year, the Care Quality Commission found that two out of five maternity units in England were providing “substandard care to mothers and babies” — a disturbing review preceded by another damning inquiry, Dr Bill Kirkup’s three-year investigation into mass failings at East Kent Hospital Trust’s maternity care. Between 2009 and 2020, he concluded, 45 babies who died under the trust’s aegis might have survived had they received “nationally recognised standards of care”.

Taken individually, these scandals and exposés are little more than horror stories, the sort of voyeuristic fodder rinsed out by newspapers before moving onto the next tragedy. Taken together, though, they are symptoms of a greater problem: our maternity service’s dysfunctional relationship between management, staffing and patients across the board. And there is something unique about this dysfunction: while the Bristol heart scandal during the Nineties revealed how a combination of ineptitude, arrogance and an old boys’ culture had contributed to dozens of babies suffering brain damage and death following cardiac operations by surgeons, today we are seeing cases, such as Letby’s, in which the “heroes” are senior consultants who come up against bloated, self-serving and intransigent management.

Over the past days, weeks, months and years, my colleagues and I have repeatedly called for senior managers in the NHS to be more accountable. The Letby case clearly illustrates — along with the East Kent, Bristol, and Mid-Staffs scandals, the latter in which anywhere between 400 and 1,200 patients died as a result of poor care between 2005 and 2009 — there is zero jeopardy for the legions of NHS senior managers when things go wrong, and lives are needlessly lost. As Dr Breary has pointed out, a “structure akin to the General Medical Council or the Nursing and Midwifery Council” solely for NHS managers is needed to “monitor the integrity, competence, and conduct of senior NHS executives”.

But I would go further. Within its health sectors, the NHS has too many managers floating between various levels of management. This murky bureaucracy has created a culture in which weaker and weaker talent fails upwards, driving out many consultants at board level who simply can’t cope with the cumbersome ineptitude of senior management committees. Once they have ascended to management positions, people who were mediocre on the wards vent their petty grievances and exert their lack of talent by putting consultants in their place. It’s an open secret that NHS management has become a gravy train, an opportunity to put your feet up and “protect your workload”. If anything, this cynicism, laziness and inertia is as deadly as the rare cases of pure evil.

No doubt there will be those with questionable “leadership skills” who view my and colleagues’ calls for an audit of management capability — and culpability — as a witch hunt. But we’re willing to take that risk. There’s clearly something rotten at the heart of the NHS.