Countess of Chester – What should happen next

In the last couple of days, we have heard news of another spate of paediatric deaths and sudden collapses at the Birmingham Children’s Hospital over the last year or so, which have been reviewed and led to the arrest of a nurse. Time will tell in this instance whether there were concerns raised early enough, whether they were listened to, whether all the incidents of concern were reviewed sufficiently. But a week or so on from the Letby verdict, with a background of maternity scandals across various trusts, it raises the question of scrutiny and investigation within the NHS itself.

I was not involved in the Lucy Letby trial. But I was involved in the early investigations in 2016, representing one family at the inquest into their baby’s death at the Countess of Chester, investigating his death from a possible Clinical Negligence point of view, and investigating the sudden collapse of another baby.

The government has announced there is to be a public inquiry. It is imperative that this be done soon, that its remit and scope is not watered down, and that its recommendations are implemented. I would also argue that action needs to go further, with a review of the entire structure and workings of the NHS, to see how these issues can be addressed across the country.

One of the key issues which has arisen appears to be the concerns raised at the time by other staff regarding Letby’s actions, and the dismissive response they apparently received. But even aside from the exceptional circumstances of murder in this instance, these concerns regarding whistleblowing are unfortunately not new. We’ve seen it before with other Trusts, such as Bristol and Great Ormond Street. One of the medical experts I work with has described whistleblowing as being akin to a crucifixion, inferring the likely response by a Trust and managers to staff concerns and the effect on one’s reputation and career.

A very recent example is the investigation covered by BBC Newsnight in December 2022 about the treatment of whistle-blowers and their concerns being ignored at University Hospitals Birmingham NHS Trust (Clinical Negligence claims set to rise if NHS whistleblowers demonised). So, this is clearly not a new problem. Where there is such clear and continuing tension between clinical staff who raise concerns, and managers who are juggling finite resources, staffing restrictions and wanting to protect their own positions, the logical solution would be for an independent body or ombudsman to deal with these issues. Arguably, there is no greater concern that can be raised, than that of a clinician potentially deliberately harming vulnerable babies, and if a Trust is ignoring such concerns and rejecting calls for investigation, the system needs to be examined and made more robust.

The second issue which needs to be addressed is that of review and investigation processes. Even in 2015 and 2016, before we knew of the exceptional circumstances involving murder, it was clear that the Countess of Chester were not following the processes that they should have been. A Serious Untoward Incident (SUI) investigation and report should have been carried out and prepared following the particular death I was looking into, and in relation to the other baby’s collapse. We received nothing from the Trust. After months and months of badgering, they provided one sheet of paper that was all but blank save for a couple of sentences. No other documentation regarding the investigation itself was provided either.

At the same time as this was going on, the unit was being reviewed by the Royal College of Paediatricians and Child Health (RCPCH), and they published their report in November 2016. The very first two immediate recommendations were that a “thorough external, independent review of each unexpected neonatal death between January 2015 and July 2016” be conducted, to determine whether any factors could have changed the outcomes, and that there be “clear, swift and equitable processes for investigating allegations or concerns which are followed by everyone”. Whether the police investigation counts as a ‘thorough, external and independent review’ of each death is a question in itself, but I hope that the inquiry still does this, through the wider context of the Trust as a whole, and examination of their processes relating to the investigation of incidents and concerns raised.

The Serious Incident Framework was not new at this point; it had been in place across Trusts nationwide for some time, and should have been utilised accordingly. There should also have been SUI investigations done relating to all the other neonatal deaths and collapses that were of concern during that period. Processes need to be clear and straight forward for Trusts to follow, and guidance needs to be clear with regards when investigations need to be started, who incidents need to be reported to, and how they are to be conducted. The CQC then needs to be given the authority and the resources to check on a regular basis that these processes are being followed in every single Trust.

A final recommendation I would make is for a nationwide continual analysis of data into neonatal deaths, as well as serious injuries caused to neonates and stillbirths, so that potential trends can be identified sooner. This does not just stem from the Letby case, but also from the various other maternity scandals we have seen in recent years. We have a breadth of knowledge and data at our fingertips, and this could be harnessed with collaboration across organisations, to keep an eye on any trends, which could prompt an independent examination and allow for action to be taken much sooner.

The cliche of ‘lessons must be learned’ stands true, but these words are hollow and meaningless unless real action is taken soon with an inquiry, implementation of recommendations and a nationwide consideration of how to resolve these issues across Trusts.