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The Parliamentary and Health Service Ombudsman has written to the Health Secretary urging him to prioritise improving patient safety in the wake of the Lucy Letby trial.
Rob Behrens has called for the proposed inquiry into the events at the Countess of Chester NHS Foundation Trust to have statutory status, so that it has use of all the legal powers available to get to the truth of what happened.
He also said that the Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. This is because there is widespread agreement that the current landscape is too crowded and confused, with significant overlaps in function that create uncertainty about who is responsible for what and this must be tackled head on.
There also needs to be a thorough review by the Department of Health and Social Care and NHS England to scrutinise the lack of compliance with the Duty of Candour.
He added in his letter: “Time and again we see mistakes repeated across the NHS and the system as a whole is not learning from this experience. We cannot let the environment in which Letby was allowed to perpetrate her crimes emerge again. What we heard during the trial was a culture of defensive leadership, a leadership that was more concerned about reputation than patient safety.
“Clinicians were not listened to when they raised concerns. They were silenced and treated as troublemakers, and threatened with disciplinary action.
“Although the appalling actions of Lucy Letby are extremely rare, unfortunately, the culture of fear in NHS trusts is not isolated to this case. Leaders dismissing the concerns of staff is a pattern of behaviour that we see repeated across the NHS. I see it in our casework. It is a feature of a number of independent reports into Trusts across the country. I hear it when I speak to medical professionals. Some still pay a heavy price for speaking up and this victimisation discourages others from coming forward. It is unacceptable and against the principles of what the NHS stands for.”
Government launches independent inquiry
Last week, the government ordered an independent inquiry into the circumstances behind the murders and attempted murders of babies at the Countess of Chester Hospital, following the guilty verdict in the trial of former neonatal nurse, Lucy Letby.
It was launched to ensure vital lessons are learned and to provide answers to the parents and families impacted. The inquiry will investigate the wider circumstances around what happened at the Countess of Chester Hospital, including the handling of concerns and governance. It will also look at what actions were taken by regulators and the wider NHS.
Lucy Letby was given a whole life sentence earlier this week.