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Responding to poor care in nursing


George Coxon reflects on the horrors of the Letby case, and asks how should the profession now respond, to maintain confidence of the public.

When I first planned to write an article on ‘responding to poor care,’ it was prompted by a recent series of high profile stories about problems in care homes. The negative press was concerning me, and I felt there needed to be discussion about what to do. But as former nurse Lucy Letby starts a whole life sentence for her crimes while working in neonatal care, this topic now feels an even more considerable challenge. There will be an inquiry; lessons will need to be learned. What does our response need to be?

My mental health care nursing career is steeped in attempting to understand before condemning those that offend, do bad things, make sometime catastrophic life-changing mistakes, or indeed hale from desperately traumatic early life neglect and abuse. Letby’s case, though, leaves me trying hard to fathom the fuller story of her history and her motives for such heinous crimes.

How do we reconcile Letby’s conduct in a role associated with the most compassionate and dedicated work, where she was looking after the most vulnerable of humanity?

Part of my senior clinical history has been spent dealing with alcohol and drug fuelled offences and leading work in local prisons, assessing pre-release offenders, and running groups under the title ‘rehabilitation’. Rehabilitation is a luxury not likely to be afforded to Letby. Not many persistent and intractable maladapted behaviours lead to whole life sentences; only four women in history have received this outcome, Myra Hindley being one, where custody and incarceration is the only course of action.

In the past, I’ve written about sex offending and also knife crime, where I attempted to reflect there on the ‘understand before condemn’ mantra. It was a struggle for both topics and did generate a good deal of mixed response.

The truth is, mistakes are often made in health and care settings, whether that’s in a care home (where I am a strong advocate for promoting positive risk taking, balancing being safe with having fun and enjoying a life that includes doing exciting and sometimes daring things), on a hospital ward, or in a primary care consultation room.

Letby’s case, like Beverley Allitt before her, of course illustrates that there is a massive difference between active abuse with malicious intent, inadvertent neglect and an omission or error brought about due to perhaps forgivable mistakes.

So, how should we respond to poor care in the future?

My question is: will the lessons learned from the Letby case apply the equally crucial principle of ‘proportionality’?

I do believe there is a need to apply a degree of tolerance for some of the ‘imperfections’ that take place in health and care work, without of course defending the indefensible or colluding with ‘poor care’.

So often, we see a huge industry of energy, resource, and the commodity we can least afford in our health and care system, namely – time!

Such a lot of time is likely to be spent compiling tougher tighter rules, restrictions and increased regulation, as a result of Letby’s despicable attacks on the babies in her care.

How are the consequences of her actions likely to affect every nurse and health and care worker?

I hope that the learning we apply, like those from Allitt, Shipman, and a handful of others before, will enable a proportionate response – where we all reflect and share more stories of great care, so as to reassure the population that Letby was an abhorrent aberration and extreme example of an otherwise dedicated profession driven by kindness, devotion and all the values instilled in nurse competence.

As to the principle of ‘understand before we condemn’: I will continue to adhere to this in my approach to my work. But I must say, Letby’s case has seriously tested my ability to be objective and impartial – a feeling that I suspect others will share.

I’d be really interested to hear about how others feel about the nature of responding to poor care. Do get in touch, and let’s share ideas on what we can do better, and more of, to help prevent any repeats of this terrible case.

George Coxon is a mental health nurse and care home activist!