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Early lessons from Letby

There are few things more repugnant in civilised society than the murder of children and babies. The revulsion is further compounded in the case of Lucy Letby in that she was a nurse and, as such, among the most trusted of professionals.

Letby has been convicted of the murder of seven babies and the attempted murder of a further six and will face a lifetime behind bars as a consequence.

While the thoughts and prayers of everyone at Bettal are with the babies, the babies’ families and all involved in bringing Letby to justice, we also need to ask the question, what lessons can health and social care learn from this sorry incident? Surely, we owe it to those same people to try to ensure nothing like this ever happens again.

What happened?

There are several questions which need to be considered about how Letby’s killing spree was allowed to continue and why it took so long to bring her to justice.

The first question relates to the fact that the alarm was raised after the first three murders, and one attempted murder, in July 2015 at which point the trust executive were made aware of the link to Letby, but nothing was done.

A further two tragic murders and three attempted murders then occurred between August 2015 and October 2015 when a second consultant raises their concerns followed by a consultant driven review which in the February of 2016 again identifies Letby as the common link. But again, nothing happened. And so, the tragedy unfolded until a further two babies had been murdered and a further three attempted murders occurred.

What went wrong?

There is no doubting that Letby is entirely liable for her own actions both as an adult and as a professional. Others however remain culpable for their failure to act on the evidence placed before them.

There is little doubt from the testimony of the consultants involved, that the policies of whistleblowing, openness and safety within the Countess of Chester Hospital were not reflected in the actions the trust took in response to the concerns of the neonatal service consultants.

What can we do?

The first CQC quality statement, under the question in this service safe, exhorts us such that:

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Cultures of care, learning and openness cannot exist in organisations which choose to ignore them when the going gets tough or when the situation requires the exercise of courage.

While terrible events of this scale are rare, every unnecessary death, injury or mistreatment of people who are vulnerable is a tragedy in its own right. What every health and social care provider, no matter how big or small, can do is to ensure that they actively promote cultures in which positive and great care is provided and where Service Users, visitors and staff are empowered to report concerns because they know something will happen.

Such cultures grow out of the reality of action within the organisation, not just the policies and definitely not just lip service. This means leaders setting the tone, providing the role model and displaying the courage to act when things are difficult.

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


There is little doubt that at least some of the babies murdered by Letby could have been saved had the Trust acted on the evidential suspicions of their own consultants. There is little doubt that the desire not to rock the boat or a lack of courage led the hospital executive to dismiss what were well founded fears.

There remain questions about cultures of care where people either turn a blind eye or fail to act in the face of challenging situations because of fear or complacency.

Bettal urges care providers to look to the culture in their own organisation and consider first if they have a culture where people feel able to report concerns. And second, if they have a culture in which they put the interests of the Service User above any personal concerns and act when concerns are raised.

In future blogs, we will look at some strategies for growing and challenging learning cultures in care.

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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