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Learning the lessons from abuse

It's not that many weeks since this blog saw us discussing the case of the now notorious Lucy Letby and her heinous murder of seven babies and the attempted murder of a further six. We acknowledged that while Letby alone was responsible for her crimes, a cover up culture at the Countess of Chester Hospital allowed Letby to murder and attempt to murder babies for some significant time after colleagues has raised their suspicions.

Now it seems that a nurse, and carer, are in the news having been found guilty of unlawfully sedating patients so that they could have an “easy life” while at work.

What happened?

Catherine Hudson was found guilty of administering unprescribed sedative medication, to two patients at the Blackpool Victoria hospital between February 2017 and November 2018. Hudson was also found guilty alongside the Charlotte Wilmot of conspiring to sedate a third patient.

Hudson had been using zopiclone which if used incorrectly is potentially fatal, to sedate the patients and had bragged about doing so in messages to other staff stating that she had sedated one patient to “within an inch of her life”.

Hudson was caught when a student nurse blew the whistle having witnessed Hudson administering unprescribed zopiclone in November of 2018. The student was further prompted by the fact that Hudson had allegedly stated that “Well she’s got a DNAR [do not attempt resuscitation] in place so she wouldn’t be opened up if she died or like if it came to any harm”,

What went wrong?

Like Letby, Hudson is entirely responsible for her own actions. What is clear is that access to potentially dangerous medication in the hospital is too easy, with no, or very limited checks on stock levels versus prescribing.

What also appears to have gone wrong is that other colleagues had not challenged the behaviour, that a culture of abuse had grown on the stroke ward where Hudson and Wilmot worked and no-one had done anything to challenge it.

Fortunately in this case, and in stark contrast to Letby, the hospital authorities acted immediately the student blew the whistle and as a result doubtless protected other individuals from being treated in the same appalling manner.

What can we do?

As individuals there is a lot care staff and registered managers can do to stamp out criminal behaviour in care settings. The first of these is to recruit and retain the right people. Ensure when recruiting you probe people’s motivations for the role and the values they think are important. This might mean asking questions about scenarios when they went the extra mile or challenged poor practice.

Second be inquisitive. This does not mean being suspicious, but being alert and asking questions about what is going on around us at all times. It is too easy as a manager to just leave the staff to it, but as the person who is legally responsible for the care our teams provide, being seen, observing care and asking for feedback from Service Users are all important ways to gauge how staff are behaving. When we see something which does not appear right ask questions. If the answers are not satisfactory escalate.

Thirdly, encourage a culture which put the Service Users at the centre. This means not accepting banter or group chats which are derogatory about Service Users, nor indeed other staff. It is a short step from name calling to abuse. This is how negative cultures start and how bad things happen.


What is worrying about both Letby and Hudson is that they are not isolated cases. While they represent a thankfully very small minority of people working in the caring professions, too many people like them have jobs that they should not.

As health and social care providers, it goes against the grain to be suspicious about the activities of colleagues, but there are occasions when we must. These two cases, and countless others like them, demonstrate that all it takes for bad to prevail is for good people to do nothing.

At Bettal we applaud the actions of the student nurse in blowing the whistle and hope that she is now a practicing nurse somewhere because health and social care need people like her. Nurses, registered managers, carers and other health and social care professionals need to develop the courage to ask questions when things don’t look right and, more so, to blow the whistle when things look to be wrong.

We said it before and make no apology for saying it again:

Better to act, be proven wrong and apologise than to ignore and perpetuate tragedy.

Bettal Quality Consultancy has a comprehensive and regularly updated suite of policies, procedures and risk assessments, including for whistleblowing, safeguarding and reporting bad practice to support busy providers, registered managers and their teams in the provision of CQC compliant care.

If you would like to know more, browse our website, or get in touch:

Telephone: 01697741411

Peter Ellis MA MSc BSc(Hons) RN


Bettal Quality Consultancy

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