We’ll probably never know what drove British paediatric nurse Lucy Letby to murder seven of her tiny patients and attempt to kill six more.
What we do need to know is why hospital management refused to listen to the doctors who tried to warn them over the unprecedented neonatal deaths. They instead ordered the doctors to apologise to Letby.
The deaths and injuries to the infants occurred in 2015 and 2016, in the neonatal unit of the 650-bed Countess of Chester Hospital in the UK.
Letby was only arrested in July 2018, at a time when she was saying the complaints about her care were unfounded.
Since then, the wheels of justice have turned slowly, as complex in-depth investigations have proceeded.
Doctors said they had raised concerns about Letby in 2015, but managers had not acted.
Dr Stephen Brearey, the head consultant at the neonatal unit, said the killings could arguably have been prevented as early as February 2016 if executives “had responded appropriately to an urgent meeting request” from concerned doctors.
We’d all like to think the silver lining is that doctors and administrators will take heed of this case and act earlier in the future.
But it’s not that simple.
The complexity of modern healthcare, especially in major hospitals, means that disturbances to the ebb and flow of work can be highly disruptive and often hard to interpret.
The big question when something seems amiss is whether the event, the deviation, is something to be taken seriously or something that can be safely ignored.
When swimming on the surface of the true facts, fine judgement is needed to pick the difference, and we will not always get it right.
But with an accumulation of such events — and events did seem to accumulate in the Letby case — red flags should be raised and responded to.
Reluctance to cause an upheaval may further delay progress, and avoidable harms result.
Let us suppose we were working at the Countess of Chester Hospital and suspected something was amiss in the neonatal ward. When would we call attention to events? How would we proceed?
I got an idea of just how difficult it is to know when to speak out when, in 1999, I attended the Lambie-Dew Oration, an annual celebration by the Sydney Medical School commemorating two foundation professors of medicine and surgery.
That year, Dr Stephen Bolsin, the UK anaesthetist who exposed the Bristol heart scandal, was the orator.
A newly appointed and youthful consultant in 1989, Dr Bolsin had been disturbed by the history of deaths of children undergoing cardiac surgery at his hospital, the Bristol Royal Infirmary.
He concluded that many of the deaths had occurred because of incompetent care, including incompetent surgery.
Dr Bolsin was ostracised for his stand.
He disturbed the conservative power structures within the paediatric cardiac surgery services at Bristol.
He also disturbed the senior hospital bosses.
So intense did the criticism become that he quit and emigrated with his young family to Australia for a fresh start.
Dr Bolsin addressed medical students and graduates in the Great Hall of the University of Sydney. When we came into the hall to sit down, we found a plastic whistle on each of our seats.
Dr Bolsin explained that, as he told us the Bristol story, we were to imagine being part of it.
At the point in the narrative when we felt we would take our concerns about patient safety to a higher authority, administrative or clinical, we were to blow our whistle.
No-one in the audience, including me, blew our whistle at any stage.
It was a powerful lesson in the restraining, paralysing power of peer pressure.
Dr Bolsin spent six years confirming the high mortality rates and attempting to improve the service.
This led to a fall in mortality rates for children’s heart surgery in Bristol from 30% to less than 5%.
It also, however, led to direct confrontation with paediatric cardiac surgeons whom the hospital refused to investigate.
Dr Bolsin eventually took his concerns to the media and became a whistleblower.
His actions led directly to a major government inquiry, the Kennedy Report, which made wide-ranging recommendations about the reform of clinical governance in UK hospitals.
In essence, district boards were charged with responsibility for clinical governance, a concept that was not well developed in NHS at the time. (For more information, watch Dr Bolsin on the Whistleblower Interview Project.)
Let’s look at another example from 20 years ago — again British, and again a series of clinical failures. It happened at the Mid Staffordshire Hospital, which was plagued by chronic staff shortages that eventually led to inquiries revealing major deficiencies.
The estimate is disputed, but it has been suggested that 400-1200 patients died as a result of poor care between January 2005 and March 2009.
Misdiagnosis was common, and many patients went without even basic care such as pain relief. Many patients were sent home before they were ready, only to end up back in hospital.
Junior doctors were left alone at night, and medical receptionists with no training were allowed to assess patients coming into the emergency department, including those needing urgent care.
Again, there were four prominent aspects to the disaster. First, many staff knew about the problems. Second, they were afraid to report them. Third, when they did report them, nothing much was done to solve them. And fourth, whistleblowers were punished.
Has much changed?
Indeed it has, but a recent anonymous English post on social media suggests that detecting and correcting poor-quality practice remains a major challenge, and that practitioners and managers are still reluctant to blow the whistle.
He or she writes: “Afraid still happening in the NHS. Staff are too afraid to speak up due to the position and status of those directors/CEOs of [hospitals]. Same people with power who are responsible for your salary, which one needs to support one’s family.”
Mustering the courage to alert even sympathetic allies in the political, administrative and clinical fields to clinical misdirections is not easy. We are all timid. Our educational processes are doing better at discussing these matters openly, but there is plenty of space for more.
We do so well with technological advances in healthcare, and our expansive data systems grow day by day. Now we need to match those advances with others in the practice of clinical governance.
There’s a legal element here as well.
As a nation, we should do more to enable and protect whistleblowers and secure their freedom, as the journalist Peter Greste argued recently.
In Australia, he said, the laws that protect both whistleblowing and media freedom are failing.
Professor Stephen Leeder is an emeritus professor of public health and community medicine at the Menzies Centre for Health Policy and School of Public Health, University of Sydney.