Lessons from Letby

The trial of Lucy Letby, a former neonatal nurse who has been convicted of murdering seven babies and attempting to murder six others, has sent shockwaves throughout the healthcare profession.

IHPN’s Director of Regulation, Dawn Hodgkins reflects on the immediate aftermath of the trial and what it means for the independent sector.

Like many people, I have been reflecting and thinking a lot about the Letby trial. It’s a horrific case, and my thoughts are with the families of the babies who were killed or injured – they will all carry the burden of these appalling crimes for ever.

It brings into sharp focus the horrendous impact on patients (babies in this case), families and staff teams that can come when healthcare fails to listen and hear concerns. It drives right to the heart for the need to seriously address the commitment to phrases we’ve heard, and use, such as openness, transparency and patient safety.

As I write this, just a few days after the verdicts were made public, the details are still being pored over, and there has been an enormous amount of discussion, commentary, and a fair bit of blame already apportioned.

There has been criticism of senior management (which includes clinicians) both within and outside of the trust. Staff have been suspended. There have been calls for greater regulation, or changes to regulation – potentially to include senior managers.

There have been questions asked about whether whistleblowers were ignored or silenced in this case, which in turn has given way to wider cultural questions about the NHS and health care in general.

Many former whistleblowers have made the claim that these issues are systemic and deep rooted, with attacks coming against some of the systems and processes which are supposed to prevent these kinds of tragedies.

There is clearly and rightly a call for a swift, but also forensically thorough investigation, which will give the families the answers they rightfully deserve as to what went so terribly wrong.

It would be completely inappropriate for me, at this early stage, to speculate on any of this, or discuss what might, or might not have occurred in this case and what could or might have made a difference.

However, equally, it would be quite wrong to not stop and take heed of this terrible case and use it as a moment when we ask ourselves difficult and searching questions.

In the independent sector, these questions are particularly important. Independent healthcare providers often have smaller staff teams and fewer resources than NHS hospitals. This can make it more difficult to create an environment where staff feel comfortable raising concerns about patient safety.

However, it is essential that independent healthcare providers create, nurture and sustain this culture. A culture of openness and transparency is essential to preventing patient harm. It allows staff to speak up when they see something wrong, and it helps to identify and address risks to patient safety.

The Lucy Letby trial is a reminder that patient safety is everyone’s responsibility – not just one staff member, or one group. It’s down to everyone, working collaboratively, and in a non-judgemental, supportive way, showing a high degree of clinical curiosity, to be continually asking ourselves questions about the care we are giving, every single time.

Are we learning? Are we as good as we can be? What could we do better? Are there any warning signs? Where are there risks? Are we listening, hearing and acting on what we are being told?

So how can we do more to create the safest possible environment?

Well, there’s plenty to do with having the right processes, policies, systems and procedures, so if I was back working within an organisation in a clinical leadership role, the kinds of questions I’d be asking include:

  • Are our policies and procedures for monitoring and responding to patient safety concerns fit for purpose, clear and unambiguous with the patient at the centre?
  • Do we provide training for staff on how to identify and report potential safety risks? How rigorous is it? How engaged are staff with this and do we all have the same commitment to patient safety?
  • What’s our system for collecting and analysing data on patient safety incidents. Do we have a common, agreed view of data definitions such as expected or unexpected? Do our processes seek assurance or reassurance?
  • Do we use the data to identify trends and patterns that could indicate potential safety risks?
  • Are we following through with taking action and embedding change to address any safety risks that are identified?

Culture, as well as policy

But, creating a culture of openness, honesty and safety is more than this. The wider cultural challenge is not just having the policies on the shelf, but how we actually get every member of staff to live and breathe them every day. For me this is about:

  • Having a united voice from ward to board that patients are the priority and the purpose of the organisation.
  • Making sure everyone is clear on the standards expected of all staff be they regulated professionals or non-regulated and consequence for not measuring up to those standards.
  • Ensuring that staff feel able to raise concerns, without fear of reprisal and that they are listened to and heard.
  • Having a clear whistleblowing policy in place that is clear, unambiguous and tested.
  • Creating a culture of continuous learning and improvement.
  • Encouraging staff to ask questions and challenge the status quo.
  • Investing in staff training and development.

Freedom to Speak Up

A few weeks ago, we saw data published about the Freedom To Speak Up Guardians (FTSU).

There are some who are critical of the FTSU initiative, but I believe it has been a welcome development, with more than 1,000 guardians now working across the healthcare sector to champion best practice and support staff. We at IHPN believe that there should be even more guardians in the sector and are very supportive of any efforts to bring in more.

The latest survey found that independent providers make up 21% of organisations, with 24% of guardians, but are only reporting 3% of cases. Conversely, NHS trusts (where admittedly this has been introduced for longer) make up 34% of organisations and 39% of guardians, but account for 92% of all cases!

It could be (and I very much hope this is the case) that this is because in some respects the culture in the independent sector is good – I know that many organisations have worked really hard on developing a culture of respect and civility within their teams. It may also be a factor that the elective services environment is naturally different from the acute and emergency pathways, as well as mental health.

So, while it is difficult to ‘compare’, it probably also suggests there is some under-representation of speaking up cases and of FTSU Guardians in the independent sector.

This could be due to a number of reasons as above, but we need to remain alert to the fact that it could be due to other factors, including a lack of awareness of the Freedom to Speak Up process and the guardian role, a fear of reprisal, or a belief that speaking up won’t make a difference.

Whatever the reasons, it is clear that more can always be done to create a culture of openness and trust in the independent healthcare sector. This will require a concerted effort from all stakeholders, including leaders, managers, and staff.

Good Medical Practice

By a quirk of scheduling, we’ve also just seen (the same week as the Trial sentencing) the publication, by the GMC, of new guidance which gives a major update to guidance first published in 2013. The guidance sets out what we can and should expect of doctors on the medical register.

It was really insightful and interesting for me to have been on the advisory forum for this important guidance. I was pleased to reflect that the new guidance is certainly stronger and much clearer – particularly for those in formal leadership or management roles – that they “must take active steps to create an environment in which people can talk about errors and concerns safely.”

In closing, I wanted to add a few specific thoughts for clinical leaders.

Be a role model for openness, transparency and civility. Let your staff know that you value their input and that you are open to hearing their concerns.

Create opportunities for staff to learn and grow. This could include providing training on patient safety, quality improvement, or risk management.

Visibly celebrate successes and learn from mistakes. When things go well, take the time to acknowledge the hard work of your staff. When things go wrong, use it as an opportunity to learn and improve, but without blame!

Celebrate staff who speak up. This shows that you value their contributions and that you are committed to creating a speaking up culture.

By creating a culture of openness and transparency, we can make our hospitals and care, wherever it is delivered, safer for our patients and our staff.