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| Case of Lucy Letby If NHS doesn't stop defensive leadership, other infants may suffer injury. |
The health service ombudsman has issued a warning in the wake of the Lucy Letby case that more babies would suffer unless "systemic changes" are done to stop the "defensive leadership" and terrible treatment of whistleblowers in the NHS.
The new wave of baby mortality incidents, according to Rob Behrens, had "lots of similarities" to the management at the Countess of Chester hospital who refused to take anything despite repeated complaints about the neonatal nurse.
He warned that England's maternity and neonatal services must reform quickly or more infants will suffer in an exclusive interview with the Guardian.
Senior physicians on Letby's unit frequently voiced worries about her connection to the rise in inexplicable fatalities. But her heinous deeds weren't finally put an end to until the first of July 2016.
According to Behrens, health professionals must be "able to raise patient safety issues" and do away with the "tribal approach" amongst various professions like doctors and nurses.
The hospital's executive team, according to Dr. Stephen Brearey, a consultant pediatrician who was the first to inform a senior executive of Letby's connection to unusual deaths and collapses, has a "anti-doctor agenda." This, he claims, explains in part why senior executives treated the consultants' concerns as "a case of doctors picking on a nurse."
"The Letby case is unusual, horrifying, and not indicative of the goals and deeds of the vast majority of committed NHS staff," Behrens added. However, it again calls into question the many NHS trusts' dysfunctional adversarial cultures, ineffective procedures for disclosing and looking into misconduct, and intolerable attitudes against making complaints and blowing the whistle.
"Although Lucy Letby's horrific actions are highly uncommon, the atmosphere of fear in NHS trusts is regrettably not limited to this one instance. We frequently observe a pattern of behavior in the NHS where leaders reject staff members' concerns.
"Some still suffer severe consequences for speaking up, and others are deterred from doing the same by this victimization. It is wrong and goes against the values upheld by the NHS.
The evidence supporting this is piling up, Behrens continued, "The reality is that the picture across many maternity services in the NHS is bleak. Compared to other health areas, maternity services have received the most policy suggestions, and there have been recent, severe, and well-documented major service failures.
Since 2015, three significant investigations have exposed grave shortcomings at the Morecambe Bay, Shrewsbury and Telford, and East Kent NHS hospital trusts that resulted in newborns being injured or dying. Currently underway is a fourth investigation into the Nottingham hospital trust.
The authorities revealed a fifth investigation into how Letby was able to kill seven newborns and attempt to kill another six last week. Bereaved families and experts have been advocating with increasing vigor for the investigation to be strengthened into a legislative inquiry where witnesses would be required to testify.
Behrens wrote to Steve Barclay, the health secretary, this week to express his support for the proposals to elevate the investigation to a legislative inquiry.
Despite several investigations into infant fatalities in the NHS, he told the Guardian that there had been "insufficient change and implementation," that progress was too sluggish, and that patients were still not danger. "It is a tragic inevitability that more women and babies will suffer until comprehensive, systemic changes to maternity care are taken seriously."
In the Letby case, Behrens claimed to have found four particular errors that mirrored patterns he had seen while looking into patient harm in other NHS maternity and neonatal departments.
"First, the trust's management and board were overly protective and more focused on protecting their organization's brand than patient safety. Second, the board failed to exercise effective leadership at a crucial juncture by not being sufficiently inquisitive or assertive.
Third, those medical professionals who frequently attempted to voice their concerns about the fatalities were directly prevented from doing so, referred to as troublemakers, and threatened with disciplinary action. Fourth, there was little or no enthusiasm for commissioning extensive independent reviews and a resistance to conducting major incident evaluations of the deaths.
According to Behrens, most people who work in the NHS do it "because they want to help," and "when things go wrong, it is not intentional." But a "defensive leadership culture across the NHS" frequently "undone" the intention of devotion to patient safety.
He acknowledged certain recent improvements in NHS safety measures, such as the establishment of a specialized maternal investigative unit, but added that "huge challenges still need to be addressed." The various public organizations charged with ensuring patient safety must also undergo a strategic review in order to improve their coordination and increase their public visibility.
When asked what would happen if changes weren't made, Behrens responded: "At a systemic level, the harms and deaths will continue to occur. Not only will families experience compounded harm, where those who have been harmed or bereaved are then subject to inadequate apologies, delayed responses, a lack of accountability, and insufficient investigations.
According to what I have observed in casework over the years, more patients will suffer injury and even die if defensive leadership, which supports defensive cultures, is permitted to persist. In the numerous independent investigations that have been conducted, we have repeatedly observed it.
The medical director at the Countess of Chester hospital, Dr. Nigel Scawn, said in a statement following the Letby verdict that the team was grieved by what had transpired and "committed to ensuring lessons continue to be learned."
"We have made a lot of modifications to our services since Lucy Letby worked at our hospital. I want to reassure everyone who will use our services that they can trust in the treatment they will get, he said.
"NHS guidance is clear, staff should be supported to raise concerns and that these are addressed," a spokesman for NHS England said. Following the verdict, we have reminded NHS leaders of the significance of this.
The organization has updated its Freedom to Speak Up guidelines, added additional background checks for board members to stop directors involved in serious mismanagement from joining another NHS organization, and now when NHS staff raise concerns, action can be taken and overseen by a non-executive who can use their independent role to hold the organization accountable.
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