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Lucy Letby case: Beware normalising the abnormal

Lucy Letby case: Beware normalising the abnormal

Dr Katie Musgrave says the dysfunctional health system enabled Lucy Letby to kill for as long as she did

The truly disturbing and horrifying details that have emerged from Lucy Letby’s case will be on the minds of NHS staff across the country. The scale of Letby’s crimes are clearly unprecedented, and the implications for clinical practice are yet to be determined. For now, we have one monstrous woman – entrusted with enormous responsibilities – who abused the trust of parents and colleagues to harm and kill the most vulnerable babies.

Even if Letby’s motives never become entirely clear, this scandal must raise far bigger questions than one mass murderer. How were systems such that so many unexpected deaths could take place without being acted upon sooner? How could people have had significant suspicions about the potential murder of babies without these being taken seriously? How could managers have moved her to an alternative role while insisting on an apology letter? And why have some of the managers responsible been able to continue in their careers without being held accountable for their part in this awful tragedy?

But I believe the most fundamental question must be whether the NHS makes patient safety enough of a priority and, crucially, what it will do in the wake of this scandal, to do this much, much better.

I was intrigued to read the suggestion from barrister Lord Carlile of Berriew that the forthcoming inquiry must appoint a foreign medical expert to avoid it being influenced by pro-NHS bias. Of course, he is right. For too long, the NHS has been allowed to mark its own homework.

And as history is beginning to tell us (I won’t list the scandals here, there are too many to name), we in the NHS have repeatedly been unable to see the dysfunction that is right before our eyes. We have normalised the abnormal, and every now and again, even more unforgivable acts slip through the cracks.

I think of my time as a junior doctor. Starting out, I was horrified at the level of responsibility I was given from my very first day. Those hundreds of inpatients I was responsible for on call overnight. I didn’t have a clue: I had no support, and I doubtless made countless serious errors due to inexperience. Those ward rounds we did post-take, where surgeons would boast how many patients they could see in a day. It was far, far too many. We were at the bedsides of acutely sick patients for sometimes only a minute, making life and death decisions on the fly. It wasn’t good enough, or safe enough. It isn’t good enough.

We do the same in general practice. Coming in, invariably the registrars complain: ‘There are too many patients, I can’t see them all safely.’ But we indoctrinate them: ‘This is just what general practice is like.’ And: ‘It’s okay, you’ll get used to it.’ They shouldn’t get used to it. It isn’t okay.

As appalling as Letby’s acts were – and I pray a million miles away from how any of us would ever behave – is there something in our healthcare system that is leaving us unable to challenge poor, dangerous, or even criminal, care? Have we become so fixated on delivering the most efficient care that we have forgotten the importance of being human? Have systems been under strain for so long that in their fire-fighting mode, good clinical leaders cannot see a way through the problems?

I’m sadly convinced that Letby’s case is a symptom of deeper malaise. Look closely in every hospital (and probably in plenty of GP surgeries, too) and you will find examples of dysfunctional services. Clinicians who have been overwhelmed by demand for so long that they cannot see a way to make things better. Situations where a callous individual could conceivably get away with crimes like Letby’s because the degree of chaos around them disguises these crimes.

Perhaps Lord Carlile of Berriew is on to something important. Perhaps the NHS needs to invite foreign experts in to inspect all our hospitals, our GP surgeries, our ambulance units, the lot. It’s time that we shone a bright light on what happens in our health service, and ask for broader opinions on what we can do better as well as what needs to urgently change.

A public inquiry into the Letby case is clearly necessary, but this alone will not stop the next scandal.

Dr Katie Musgrave is a GP in Devon and quality improvement fellow for the South West



Please note, only GPs are permitted to add comments to articles

Slobber Dog 23 August, 2023 6:57 pm

Let’s also invite foreign experts to inspect our criminal justice system which is frequently found wanting.

Joe Josephus 23 August, 2023 10:57 pm

Reminds me of the case of the Dutch paediatric nurse Lucia de berk

Sam Macphie 24 August, 2023 12:49 am

Yes, Letby the heinous nurse who murdered babies. 7 Consultant Paediatricians not listened to ( by managers earning huge amounts, much more than a Paediatrician ), and managers who are more interested in targets and potentially ‘cover-ups’ too: where was their humanity and concern for actual patients, not targets? Should some of these managers be arrested by the Police right now and questioned regarding their apparent inaction, and tried in a Crown Court? (before they do even more harm). What sort of people are they: I think most people would take the honest words of 7 Paediatricians against their lack of managerial care.

Cameron Wilson 24 August, 2023 7:20 am

Totally agree with you Sam. The fall out from this could be colossal, and is perhaps long overdue.
For the first time, management is firmly in the firing line, and it will be more than interesting their defence. What recommendations that the inevitable enquiry comes up with, could have far reaching consequences. Hopefully the days when the beleaguered front line gets slaughtered for system inadequacy will be ended, although with the GMC , am not holding my breath. If managers were to be regulated and held responsible for the clinical safety, perhaps it will focus their mind on the pressure that staff have endured for years.
The quality or quantity dilemma will become pivotal!
If some good comes out of this evil episode so much the better, just hope that it is more beneficial than the nonsense that followed Shipman. You know what I mean appraisal, revalidation etc and all the unintended consequences that those have delivered.

Jaya Aiyengar 24 August, 2023 7:30 am

Points well made, very distressing to read about the lack of accountability from the management team
My cynical view here is that if this had been a BAME professional, the complaints would have been looked into with more scrutiny!

Douglas Callow 25 August, 2023 1:25 pm

Petition: Create a new regulatory body to hold NHS managers accountable

we need as many people as possible to sign this,similar%20to%20doctors%20and%20nurses.

David Church 25 August, 2023 10:13 pm

Unprecedented. But only since Shipman.
That time, doctors noticed, acted appropriately and reported: managers told them to shut up (and we don’t know what more was done to them), but managers covered it up.
Eventually it was found out, the doctors were blamed, despite their having done all they couldm and we are burdened with loads of additional admin work which hampers provision of care, but is supposed to prevent Shipman happening again. Well it will not, and it would not have don ethen either, because doctors did report concerns about him far earleir, but corrupt system prevented investigation.
Anyone reading about the Countess of Chester Hospital will say this sounds familiar – because it is an identical situation. The outcome will be identically ridiculous; doctors will be blamed again – despite having acted and been overthrown and threatened – and some further ridiculous and hampering administrative burdens will be throan at anyone providing SCBU care – but it will not in any way prevent this sort of thing happeneing again, because of the corrup upper management levels that promote it. It us that corrupt topmost level that must be changed – but it is too akin to our current Government system, and the two will try to mutually support each other. But how long can corrupt Government survive?

Some Bloke 25 August, 2023 11:10 pm

Completely agree with comments above about current management system allowing more horror like this to happen. I am sure there will come more regulations and scrutiny, I am not sure it will bring much good.
Just few hours ago I drove through some weird places with traffic lights. Lot’s of technology, regulations, red and green lights and long queues of traffic. Then you get to a roundabout and see traffic is flowing seamlessly with just a painted white circle managing all of it.
They may force hospital staff to undertake more “training” and do more documentation of their every step, this will change nothing- other than less time for patient care. I already see how public will be fed same crap – go to your GP and ask for referral for your emergency appendectomy, because we have to do things properly now.
Conclusion?- nothing good will come out of this. No positive changes. Not from what I ve observed in the past 20+ years working in the NHS. (Which makes me think – why am I still doing this?)

Christine Collins 26 August, 2023 10:46 am

We need to be allowed to be curious without risk of reprimand. A system that welcomes curiosity as a quality improvement process, looks into variation (warranted and unwarranted) and allows everyone to contribute as an equal will prevent disasters in future and may create a system that cares.

Dr No 30 August, 2023 12:48 am

I’ve had the same experience with the GMC. Tried to flag up an underperforming (very) doc and was totally stonewalled. They were not interested in checking said docs credentials unless I made a formal complaint with evidence. I suppose somebody has to come to serious harm first…

Finola ONeill 30 August, 2023 1:50 pm

I listened to the paediatrician’s interview on radio 4 (the main whistle blower). He said the whole lot need investigating; NHS England, GMC, Royal College Paediatrics, CQC; as all were involved and all were aware. He is absolutely right and this has been ignored in the media and generally and the focus is just the trust managers. They exist in cahoots/collusion with NHSE (revolving door between many trust execs and NHS England managers who move between posts and all trust ceo execs are approved by NHSE and none of us thinks GMC, CQC are independent. We don’t need a flipping ‘a foreign medical expert to avoid it being influenced by pro-NHS bias.’ We need a judge led enquiry; or coroner. And we don’t have a ‘pro-NHS bias’. Just all those managers in the revolving door between NHSE, NHS trust senior posts, CQC and GMC do. Because many of them are a closed group playing musical chairs. (Some clearly are decent and I think Amanda Pritchard is and marks a move forwards. The fact she is getting rid of 60% of NHSE managers says it all).

But after Tony Chambers left Letby’s hospital he rotated through various trusts, while NHSE regional had banned him from local trust jobs, and ended up interim chief at the hospital where my sister works. QVH, east grinstead. The hospital which the local NHSE regional had been trying to push through a merger with brighton, opposed by their own governors and consultants (who voted no confidence in the previous chief exec pushing this through), because of safety concerns at Brighton, where whistle blowers including the medical director had been sacked for voicing safety concerns, and whose employment tribunal referred Brighton to the coroners, and now the police are investigation gross negligent manslaughter re their concerns. Those governors who opposed merge with hospital of concern, Brighton, NHSE regional imposed additional licence conditions on them to curtail their opposition and control them. Bearing in mind it is the governors statutory duty to approve any merger of their hospital. Licence conditions still in place, after chief exec consultants voted no confidence in left, NHSE regional shoe horned in Tony Chambers. So no one say this is not a revolving door and endemic problem of all the layers of NHS Management.

Safest thing about General practice is we don’t have these managers or have to answer to them.
And Katie. We don’t normalise the dangerous working levels. We are stuck with them. WE do our best while having a contract unilaterally imposed by this government.

And none of us including the public have a pro NHS management bias. We have a bias for the public system and doctors, nurses and staff that do our best in this underfunded system.
I don’t find anyone normalising it. Either here, in the media or anywhere else.

What I am really interested in if Katie quotes a pro-NHS bias what alternative is she preferring? A private healthcare system?
Or an NHS with management much pared back and overseen by a truly independent body. The latter is what I want. As Amanda Pritchard cuts the 60% NHSE managers I live in hope.
Maybe we can introduce a truly independent body for oversight of/ regulation of NHS trust managers, NHSE managers and related quangos CQC and GMC.
Plus pared back versions of all of these.
Living in hope.

(‘Chairs should discuss plans to recruit chief executives with the relevant NHS
Improvement executive regional managing director (or in their absence, with the
relevant director of improvement and development).’)