The independent inquiry into the circumstances behind the murders and attempted murders of babies at Countess of Chester Hospital by Lucy Letby must be given statutory status, the NHS ombudsman has said.
Parliamentary and Health Services Ombudsman Rob Behrens has written a letter to the health and social care secretary, Steve Barclay, stressing that the inquiry ‘should have all possible levers available to it to get it to the truth’.
This follows the sentencing of Letby to a full life sentence for the murder of seven babies, and attempted murder of six others.
Last week, the Department of Health and Social Care (DHSC) ordered a non-statutory inquiry into the circumstances surrounding the deaths and incidents, including how concerns raised by clinicians were dealt with. In a statement on 18 August, the DHSC said a non-statutory inquiry ‘was found to be the most appropriate option’.
In its current status, the inquiry does not have the legal power to compel witness to give testimony or demand the release of evidence.
However, Mr Behrens told the health secretary that ‘the families involved deserve no less’ than a full statutory inquiry.
‘We cannot let the environment in which Letby was allowed to perpetrate her crimes emerge again,’ he added in his letter to Mr Barclay.
‘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.’
Mr Behrens comments come after it emerged that the Nursing and Midwifery Council will continue a fitness to practise investigation into Letby’s former manager, who allegedly dismissed concerns about Letby raised by clinicians.
Alison Kelly, who was a senior manager in charge of nursing at the Countess of Cheshire Hospital during the time in which Letby murdered seven babies, has also been suspended from her current position.
In his letter, Mr Behrens said that while Letby’s actions are ‘extremely rare’, the ‘culture of fear’ that led to complaints not being investigated were not isolated to this case.
‘Leaders dismissing the concerns of staff is a pattern of behaviour that we see repeated across the NHS,’ Mr Behrens said.
‘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.’
The ombudsman also called on Mr Barclay to ‘commission an independent review of what an effective set of patient safety oversight bodies would look like’.
Additionally, Mr Behrens wrote that the DHSC should provide a ‘clear commitment to embedding the culture and leadership needed to ensure patient safety is always the top priority’.
Mr Behrens said this would mean ‘addressing the problems of defensive leadership that are still too common across the service’, and urged Mr Barclay to ‘conduct a thorough, independent review with cross-party support of NHS leadership, accountability and culture’.
The DHSC was approached for comment.
