UK - Lucy Letby - Post-Conviction Statutory Inquiry

[Tortoise]

Next week's witness timetable Witness Timetable | The Thirlwall Inquiry

Week 4 – Part B evidence​

Monday 30 September	Sir Robert Francis KC – Expert Witness
Tuesday 1 October	Dr John Gibbs – Consultant Paediatrician
Wednesday 2 October	Dr Rachel Lambie – Paediatric Registrar Dr Matthew Neame – Paediatric Registrar Dr Huw Mayberry – Paediatric Registrar (remotely) Dr Cassandra Barrett – Paediatric Registrar
Thursday 3 October	Dr Elizabeth Newby – Consultant Paediatrician Dr Murthie Saladi – Consultant Paediatrician Dr Suzy Holt – Consultant Paediatrician

 

[Marantz4250b]

I think the serial killer nurse is always going to find a way to do harm, knowing what the cameras capture and don't capture. I think what went wrong in this case could be prevented with a better system of flagging up unexpected events, and communication of that to all senior team members, adhering to rules about two person procedures, and regular training and preparedness to think anybody, whatever impression you have of them, could be causing deliberate harm, or independent and rapid evaluation of serious incidents from an outside agency, who does not know the personnel at the hospital.

And this is the salient point, imo. Someone who is intent on doing something illegal is going to do it. Whatever safeguard you put up is just a obstacle for someone to negotiate. These things might stop some people and might make the careless or reckless consider their actions more but anyone with highly nefarious intent is going to find a way. Someone who is actually worried about the consequences of being caught will be deterred but the true criminal wont be - my grandfather used to use the phrase ...locks are only to keep honest folks out.... In the end, I think that LL reached a point where she either didn't think she'd be caught or didn't care if she was.

Don't get me wrong, when we discussed this months back I was quite in favour of having cameras on patients but for all the reasons mentioned I don't see much benefit and the privacy issues alone outweigh any benefit, I think.

The second highlighted point is the real issue here; the issues relating to LL were most certainly flaged by the group of doctors but management simply dismissed those concerns and even made threats towards these doctors. The system actually worked well as regards this stuff being brought to the attention of the relevant people, it's just that the relevant people didn't act on it and even appear to have acted in such a way as to make the problem of LL even worse. This, imo, is going to be the main conclusion of the inquiry.

When a group of senior, highly experienced doctors are all saying the same thing you should be taking that as face value and investigating.

 

[Marantz4250b]

It's awful to think that there is the potential to generalise a cause of death due to prematurity in the same way as if the victim is very elderly

I didn't think they recorded things like that anymore. Didn't it change after Shipman? He was writing causes of death as "old age" but old age doesn't kill you - specific physiological things do - like your heart stopping, for instance.

Speaking as a totally uneducated person as regards medical stuff, it's surely the same as regards prematurity? Things caused by the prematurity cause death, not prematurity per-se?

 

[Tortoise]

It's hard and I understand the recent fears of some of the medical staff now because if the coroners start automatically looking at each case as if it could be suspicious death, then is it more probable that various nurses or doctors will be suspected and accused of harm, even if innocent?

I'm not sure every death needs to be looked at by the coroner as if it could be suspicious. If there was a system of ticking a box marked "unexpected", and a further box to elaborate on the medical history, signed off by two doctors so that there is oversight to make sure the box is ticked where appropriate, it would only happen where warranted.

 

[Ruthbullock]

Imo this article is bang on ...the no blame culture and procedures to "better" staff who are incompetent or "bad apples" are extreme.
We often said it's virtually impossible to.lose your job in the nhs

I think that’s true in many many places sadly- it always surprises me though that nothing was put in place. I understand it swings both ways and often HR may stick to the side of caution before going all in- but where are the in between steps. Liverpool women’s hospital saw issues, did they implement a training plan, or monitoring plan, or were they just glad to sign off on someone and send them elsewhere in the hope they would do better? Complaints were made at the countess and she was moved off ward duty- but then what, how they mitigate or improve or monitor her practice, or did they just send her back onto the wards. There is a lot of “well this was our scope of engagement and we did our bit”- which ultimately ended up with nothing being actioned anywhere- but I’m sure lots of paperwork and tick boxes completed.

 

[Ruthbullock]

It seems hospitals, or at least the two mentioned lack any sort of internal protocol for investigating concerns and it’s a big leap to being sacked via HR or even suspended without those intermediary procedures normally happening. There policy below will have been updated now I’m sure, but there were so many other routes that should have been taken, not just well we told HR and they didn’t take us seriously

https://www.coch.nhs.uk/media/86654/pf_revised_and_agreed__new_concerns_about_patient_care_and_whistle_blowing_policy__v4_mg_16.12.13.doc

 

[Ruthbullock]

LADO, existed at the time and is independent of the place of work, and not as formal as the police- we used it in schools and childcare settings and it was equally pushed for NHS and care settings- were they ever informed?