Lucy Letby verdict, a future inquiry and patient safety

  • 23rd August 2023

On 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this.

Last week the nurse Lucy Letby was found guilty of murdering seven babies on a neonatal unit at the Countess of Chester Hospital. She was also convicted of trying to kill six other infants at the same hospital between June 2015 and June 2016.[1] She received whole-life order for each offence she committed, meaning she will spend the rest of her life in prison unless under very exceptional circumstances.[2]

At Patient Safety Learning our thoughts are with everyone affected by these appalling crimes. It is shocking how this nurse was able to undertake her deliberate acts for so long, and that when concerns were raised the actions taken were not able to prevent multiple deaths and harm.

In the wake of this verdict, the Secretary of State for Health and Social Care, Steve Barclay MP, has announced that there will be an independent inquiry into the circumstances behind the murders and attempted murders of the babies at Countess of Chester Hospital.[3] Victims’ families will be invited to engage with and shape this inquiry, which will also look at how the concerns raised by clinicians were dealt with.

Understandably, given the horrendous nature of these crimes, this case has received extensive media coverage. In this article we will not seek to replicate this, but instead look towards the future inquiry. Considering the evidence presented to date, we will outline some of the key patient safety themes and issues that we believe should be considered as part of this, especially:

  1. Clinicians’ safety concerns and speaking up.
  2. Gaps in incident reporting and investigation.
  3. Failures in leadership and governance.

What type of inquiry should this be? Statutory or non-statutory?

Before discussing these three patient safety themes, it is first worth considering the nature of this inquiry.

The Government has announced that this will be conducted as a non-statutory public inquiry. Inquiries such as this are established by a government minister, but not under an Act of Parliament. Potentially this allows for the inquiry to be set up and begin its work more rapidly than a statutory inquiry, as it possesses greater flexibility on procedures and is not bound by the rules set out in the Inquiries Act 2005.[4] However, this also means the inquiry will lack the legal power to compel witnesses to give or produce evidence relevant to their work.

Concerns have already been raised about the appropriateness of holding a non-statutory rather than a statutory inquiry. Of particularly relevance to these considerations is the recent patient safety inquiry into mental health inpatient care in Essex. In this case, earlier this year, the non-statutory inquiry had to be converted into a statutory inquiry due to the extremely low levels of engagement by staff in this process.[5] [6] Since the announcement of the Lucy Letby inquiry, there have now been further news reports suggesting that the Government may now be reconsidering this decision in the wake of growing demands to put the inquiry on a statutory footing.[7]

Patient Safety Learning supports the need for an inquiry at pace, so that learning and action can be taken to prevent future harm at the Countess of Chester Hospital and more widely. We believe that this inquiry needs to be thorough, expert-led and evidence based with insights from families and staff. Given the way that clinicians' concerns about Lucy Letby were handled, it is also important, in our view, that staff are supported and actively encouraged to engage in the inquiry.

We believe that a statutory inquiry would be the best way to achieve this and that the families affected by this tragedy deserve nothing less. We support calls from the Chair of the Health and Social Care Select Committee, local MPs and lawyers representing the victims’ families to make this change.[8]

Clinicians’ safety concerns and speaking up

Turning now to our first key patient safety theme, concerns were first raised about Lucy Letby by the unit consultant, Dr Stephen Brearey, in October 2015. Dr Brearey and other clinicians involved in this case have raised serious concerns about the hospital’s approach to those who raised these issues and a failure to act on their concerns.[9] [10]

These experiences mirror patterns we see all too often across the NHS, with organisational cultures deterring staff from speaking up and responding negatively when concerns are raised. We see this reflected year after year in the results of the NHS Staff Survey, which reveal that significant numbers of staff do not feel safe to speak up or confident that their concerns will be acted upon.[11] This theme also emerges time and time again in patient safety inquiries and reviews.[12]

Creating a safety culture, where staff feel safe to speak up about concerns, is identified as a core part of the NHS Patient Safety Strategy.[13] As part of its work towards this, NHS England has recently published new guidance for Trusts to help support teams both understand safety culture and support them in improving this.[14] However, despite this work overseen centrally by the Safety Culture Programme Group, it is still unclear:[15]

  • how the implementation of good practice guidance is being monitored and evaluated; and
  • in cases where there are concerns about speaking up practices, what mechanisms are in place, if any, to identify these and, if necessary, indicate the need for intervention by NHS England and regulatory bodies.

Following the verdict in the trial of Lucy Letby, NHS England issued a letter to all Integrated Care Boards and NHS Trusts reminding them of existing provisions put in place to ensure staff feel safe to speak up, emphasising that “NHS leaders and Boards must ensure proper implementation and oversight” of these policies.[16]

At Patient Safety Learning we believe that simply issuing a reminder about existing guidance falls far short of the action needed to tackle this issue. NHS England have a leadership role in this area, but this feels more like ‘management by press release’, adding little of value other than saying ‘don’t get it wrong’.

We also note that in this letter NHS England stated that they had asked Integrated Care Boards to play a role in ensuring effective and accessible speaking up arrangements are in place. Although this may be a welcome suggestion, their role in this area is hampered more broadly by the absence of guidance concerning Integrated Care Systems and NHS Patient Safety Strategy, and their role in patient safety more broadly. As outlined in our recent report, The elephant in the room: Patient safety and Integrated Care Systems, there needs to be far greater clarity about the patient safety responsibilities of Integrated Care Systems and how these fit into the wider healthcare system.[17]

We would suggest that speaking up is a key area for the inquiry to explore in further detail. It should consider what action is needed to ensure healthcare has the right culture to hear staff concerns and recommendations for improvements, and to respond fairly and appropriately to those whistleblowing for patient safety in the NHS. The inquiry should consider this in the context of what has been said in previous inquiry reports and recommendations in this area, such as the Berwick review into patient safety, and what NHS organisations need to do to adopt and accept the recommendations for an open and fair safety culture.[18]

Gaps in incident reporting and investigation

Another key area of concern raised by the Letby case was how incidents were reported and recorded. We understand that deaths were reported to the Trust’s incident reporting system and that the Trust had classified these as “medication errors”, rather than a “serious incident involving an unexpected death”. As a result of this, they were not grouped together as the latter classification would have allowed, which may have resulted in a quicker recognition and investigation of their causes.[19]

Concerns were also raised in a Royal College of Paediatrics and Child Health review in 2016 about deaths not being classed as serious incidents and some not sent for post-mortem examinations, despite this being best practice.[20] This review also found gaps in staffing and poor decision-making.

Difficulties in monitoring safe performance in Trusts and detecting concerning patterns are not new issues, particularly in maternity care, and were a key problem raised last year by the inquiry into maternity and neonatal services in East Kent.[21] In response to a recommendation of this inquiry, the Government has committed to the prompt establishment of a Task Force to drive the introduction of valid maternity and neonatal outcome measures, aimed to make sure the right data will be used in the right way to identify and support trusts who may be vulnerable to bad outcomes.[22]

Although the cases involving Lucy Letby obviously significantly differ from those covered in the East Kent Inquiry, they do again serve to highlight concerns about the ability of Trusts to detect patient safety issues in maternity care and promptly respond to them. It also points to problems concerning whether patient safety investigations result in learning and improvement, an issue also highlighted in East Kent.[23]

We believe that this should be a key area for the inquiry to explore. The need to improve patient safety investigations has long been acknowledged by NHS England, who are currently rolling out a new Patient Safety Incident Response Framework (PSIRF) aimed at changing this.[24] This framework sets some requirements for incident investigation but provides increased flexibility for Trusts to decide their own criteria for undertaking patient safety incident investigations.[25] How this is implemented and monitored may also be of specific relevance to the inquiry’s investigations, whether the ‘Learning from Deaths’ Guidance is being properly implemented and whether this is sufficient to manage the risk of avoidable harms and death.[26]

Failures in leadership and governance

A third key patient safety theme that emerges from the Lucy Letby case relates to serious failures at a leadership level in identifying and preventing the serious harm and deaths to babies she was responsible for. Examples of this include:

  • Whistleblowers saying that the hospital could have taken more definitive action at an earlier stage when clinicians were reporting concerns.[27]
  • The former chair of the Trust, Sir Duncan Nichol, stating that Board members were “misled” by hospital executives about the severity of these issues.[28]
  • Concerns that hospital executives placed reputation management over acting on serious safety concerns.[29] [30]

The inquiry will need to look in-depth at how these issues specifically manifested themselves at the Countess of Chester Hospital. Again, this is another failing that we commonly see raised in other patient safety inquiries, including last year’s East Kent Maternity Review.

In the context of the Lucy Letby verdict, commenting more broadly on how NHS Boards approach patient safety, Sir Stephen Moss, the former turnaround Chair of the Mid Staffordshire NHS Foundation Trust and Patient Safety Learning trustee, has reflected that:

“There is a lot of rhetoric that goes on and many chairs and board members tell me that patient safety is obviously their priority. But when I follow that up by asking 'what this means in practice', the response is often disappointing. Boards and leaders need to better understand that their primary role is to provide staff on the frontline with everything they need to do their job well—and the most important part of that role is to keep patients safe.”

At Patient Safety Learning we believe that there needs to be a more effective leadership and governance for patient safety in both the NHS and independent sector. There should be high standards and behaviours set for our leaders and they should be supported by specialist patient safety, organisational development and governance experts. We are investing our time and expertise to support organisations in this, and we see effective leadership behaviours and governance as a key issue that needs further exploration by the inquiry.

Will anything change? Inquiry findings and implementation

In this article we have identified three key patient safety themes that we believe should be considered as part of the inquiry following the Lucy Letby verdict.

There has been a succession of major patient safety inquiries over the past twenty years in the UK. However, as identified in our report last year, Mind the implementation gap, far too many of these are followed by promises to learn lessons from the past, but their implementation remains inadequate and patchy and their impact left unmonitored and often unevaluated.[31] It is vital that this mistake is not made again in this case; furthermore, the Government response must ‘join the dots’ between the overarching themes that emerge from this and other inquiries where there is a clear need for action.

Good leadership should drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. We identify this as one of the six foundations of safer care in our report, A Blueprint for Action, and as a key part of our organisational Patient Safety Standards.[32] [33]

In light of the shocking outcomes of the Lucy Letby case, and the serious shortcomings at a leadership level, we believe NHS England and Trusts cannot simply sit back and wait for this inquiry’s findings and recommendations, which may be years away. Actions need to be taken urgently, informed by the inquiry, of course, but also using the knowledge and evidence from the many tragedies in the past. There needs to be a serious effort by leaders (Executives, Boards, Clinical Leaders, Integrated Care Boards, NHS England, and others) to reflect on their organisation’s approach to patient safety and for them to model and deliver high and consistent standards and behaviours, placing patient safety at the core of health and social care. We owe it to everyone who has experienced preventable harm in our healthcare system to not just say ‘patient safety is a priority’ but to act on and be held accountable for delivering this.


[1] BBC News, Nurse Lucy Letby guilty of murdering seven babies on neonatal unit, 18 August 2023.

[2] Sky News, Lucy Letby will die in prison after receiving 14 whole-life sentences, 21 August 2023.

[3] Department of Health and Social Care, Government orders independent inquiry following Lucy Letby verdict, 18 August 2023.

[4] The Telegraph, Judge-led Lucy Letby inquiry ‘would take too long’, 21 August 2023.

[5] Health Service Journal, Deaths inquiry thrown into doubt as only 11 staff agree to give evidence, 13 January 2023.

[6] UK Parliament, Ministerial Statement – Mental Health In-patient Services: improving Safety, 28 June 2023.

[7] The Independent, Lucy Letby inquiry could get statutory powers, No 10 says after pressure from victims’ families, 21 August 2023.

[8] BBC News, Lucy Letby inquiry should be led by judge, committee chair says, 21 August 2023.

[9] Health Service Journal, Revealed: How trust execs resisted concerns over Letby, 18 August 2023.

[10] BBC News, Hospital bosses ignored months of doctors’ warnings about Lucy Letby, 19 August 2023.

[11] Patient Safety Learning, Still not safe to speak up: NHS Staff Survey Results 2022, 23 March 2023.

[12] Patient Safety Learning, Mind the implementation gap: the persistence of avoidable harm in the NHS, 7 April 2023.

[13] NHS England, The NHS Patient Safety Strategy; Safer culture, safer systems, safer patients, July 2019.

[14] NHS England, Improving patient safety culture – a practical guide, 11 July 2023.

[15] NHS England, Safety culture programme group (SCPG) report: Overview of safety culture discovery and discussions 2021, Last Accessed 22 August 2023.

[16] NHS England, Letter: Verdict in the trial of Lucy Letby, 18 August 2023.

[17] Patient Safety Learning, The elephant in the room: Patient safety and Integrated Care Systems, 11 July 2023.

[18] Department of Health and Social Care, A promise to learn – a commitment to act: improving the safety of patients in England, 6 August 2013.

[19] The Sunday Times, Revealed: the files that show how Lucy Letby was treated as a victim, 19 August 2023.,witch%2Dhunt%E2%80%9D%20against%20Letby.

[20] Health Service Journal, Revealed: How trust execs resisted concerns over Letby, 18 August 2023.

[21] Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022.

[22] Department of Health and Social Care, Government response to ‘Reading the signals: maternity and neonatal services in East Kent – the report of the independent investigation’, 3 August 2023.

[23] Patient Safety Learning, Will lessons be learned? An analysis of the systemic failures in the East Kent Maternity report, 17 November 2022.

[24] NHS England, Patient Safety Incident Response Framework, Last Accessed 21 August 2023.

[25] NHS England, Patient safety incident investigation, August 2022.

[26] NHS England, Implementing the Learning from Deaths framework: key requirements for trust boards, July 2017.

[27] The Guardian, Lucy Letby whistleblower says babies would have lived if hospital acted sooner, 18 August 2023.

[28] The Guardian, Lucy Letby NHS trust chair says hospital bosses misled the board, 20 August 2023.

[29] The Chester Standard, Countess of Chester Hospital under pressure over Lucy Letby, 19 August 2023.

[30] Nick Timothy, Too many institutions put their reputations ahead of the public, 20 August 2023.

[31] Patient Safety Learning, Mind the implementation gap: the persistence of avoidable harm in the NHS, 7 April 2023.

[32] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019.

[33] Patient Safety Learning, Patient Safety Learning’s Patient Safety Standards, 21 June 2023.

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