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Countess of Chester Hospital Inquiry

Volume 832: debated on Tuesday 5 September 2023


The following Statement was made in the House of Commons on Monday 4 September.

“With permission, Mr Speaker, I would like to make a statement on the inquiry into the circumstances surrounding the crimes of Lucy Letby.

On 18 August, as the whole House is aware, Letby was convicted of the murder of seven babies and the attempted murder of six others. She committed these crimes while working as a neonatal nurse at the Countess of Chester Hospital between June 2015 and June 2016. As Mr Justice Goss said as he sentenced her to 14 whole-life orders, this was a

‘cruel, calculated and cynical campaign of child murder’

and a

‘gross breach of the trust all citizens place in those who work in the medical and caring professions’.

I think the whole House will agree it is right that she spends the rest of her life behind bars.

I cannot begin to imagine the hurt and suffering that these families went through, and I know from my conversations with them last week that the trial brought these emotions back to the surface. Concerningly, that was exacerbated by the fact the families discovered new information about events concerning their children during the course of the trial.

Losing a child is the greatest sorrow any parent can experience. I am sure the victims’ families have been in the thoughts and prayers of Members across the House, as they have been in mine. We have a duty to get them the answers they deserve, to hold people to account and to make sure that lessons are learned. That is why, on the day of conviction, I ordered an independent inquiry into events at the Countess of Chester Hospital, making it clear that the victims’ families would shape it.

I arranged with police liaison officers to meet the families at the earliest possible opportunity to discuss with them the options for the form the inquiry should take, and it was clear that their wishes are for a statutory inquiry with the power to compel witnesses to give evidence under oath. That is why I am confirming this to the House today.

The inquiry will examine the case’s wider circumstances, including the trust’s response to clinicians who raised the alarm and the conduct of the wider NHS and its regulators. I can confirm to the House that Lady Justice Thirlwall will lead the inquiry. She is one of the country’s most senior judges. She currently sits in the Court of Appeal, and she had many years of experience as a senior judge and a senior barrister before that. Before making this Statement, I informed the victims’ families of her appointment, which was made following conversations with the Lord Chief Justice, the Lord Chancellor and the Attorney-General.

I have raised with Lady Justice Thirlwall the fact that the families should work with her to shape the terms of reference. We hope to finalise those in the next couple of weeks, so that the inquiry can start the consultation as soon as possible. I have also discussed with Lady Justice Thirlwall the families’ desire for the inquiry to take place in phases, so that it provides answers to vital questions as soon as possible. I will update the House when the terms of reference are agreed and will continue to engage with the families.

Today, I would also like to update the House on actions that have already been taken to improve patient safety and identify warning signs more quickly, as well as action that is already under way to strengthen that further. First, in 2018, NHS England appointed Dr Aidan Fowler as the first national director of patient safety. He worked with the NHS to publish its first patient safety strategy in 2019, creating several national programmes. Those included requiring NHS organisations to employ dedicated patient safety specialists, ensuring that all staff receive robust patient safety training and using data to quickly recognise risks to patient safety. Last summer, to enhance patient safety further, I appointed Dr Henrietta Hughes, a practising GP, as England’s first patient safety commissioner for medicines and medical devices. Dr Hughes brings leaders together to amplify patients’ concerns throughout the health system.

Secondly, in 2019, the NHS began introducing medical examiners across England and Wales to independently scrutinise deaths not investigated by a coroner. Those senior doctors also reach out to bereaved families and find out whether they have any concerns. All acute trusts have appointed medical examiners who now scrutinise hospital deaths and raise any concerns they have with the appropriate authorities.

Thirdly, in 2016, the NHS introduced freedom to speak up guardians, to assist staff who want to speak up about their concerns. More than 900 local guardians now cover every NHS trust.

Fourthly, in 2018, Tom Kark QC was commissioned to make recommendations on the fit and proper person test for NHS board members. NHS England incorporated his review findings into the fit and proper person test framework published last month. It introduced additional background checks, the consistent collection of directors’ data and a standardised reference system, thus preventing board members unfit to lead from moving between organisations.

Fifthly and finally, I turn to maternity care. In 2018 NHS England launched the maternity safety support programme to ensure that underperforming trusts receive assistance before serious issues arise. Also since 2018, the Government have funded the national perinatal mortality review tool, which supports trusts and parents to understand why a baby has died and whether any lessons can be learned to save lives in the future. Furthermore, the Government introduced the maternity investigations programme, through the Health Safety Investigation Branch, which investigates maternity safety incidents and provides reports to trusts and families. In 2020, NHS England’s Getting It Right First Time programme was expanded to cover neonatal services. It reviewed England’s neonatal services using detailed data and gave trusts individual improvement plans, which they are working towards. Indeed, Professor Tim Briggs, who leads that programme, has confirmed that all neonatal units have been reviewed by his programme since 2021.

Let me now turn to our forward-facing work. First, we have already committed to moving medical examiners to a statutory basis and will table secondary legislation on that shortly. It will ensure that deaths not reviewed by a coroner are investigated in all medical settings—in particular, extending coverage in primary care—and will enter into force in April.

Secondly, on the Kark review, at the time the NHS actively considered Kark’s recommendation 5 on disbarring senior managers and took the view that introducing the wider changes he recommended in his review mitigated the need to accept that specific recommendation on disbarring. The point was considered further by the Messenger review. In the light of evidence from Chester and ongoing variation in performance across trusts, I have asked NHS England to work with my department to revisit this. It will do so alongside the actions recommended by General Sir Gordon Messenger’s review of leadership, on which the Government have already accepted all seven recommendations from the report dated June last year. This will ensure that the right standards, support and training are in place for the public to have confidence that NHS boards have the skills and experience needed to provide safe, quality care.

Thirdly, by January all trusts will have adopted a strengthened ‘freedom to speak up’ policy. The national model policy will bring consistency to freedom to speak up across organisations providing NHS services, supporting staff to feel more confident to speak up and raise any concerns. I have asked NHS England to review the guidance that permits board members to be freedom to speak up guardians, to ensure that those roles provide independent challenge to boards.

Fourthly, the Getting It Right First Time programme team will launch a centralised and regularly updated dataset to monitor the safety and quality of national neonatal services.

Fifthly and finally, we are exploring introducing Martha’s rule to the UK. Martha’s rule would be similar to Queensland’s system, called Ryan’s rule. It is a three-step process that allows patients or their families to request a clinical review of their case from a doctor or nurse if their condition is deteriorating or not improving as expected. Ryan’s rule has saved lives in Queensland, and I have asked my department and the NHS to look into whether similar measures could improve patient safety here in the UK.

I want to take the first opportunity on the return of the House to provide an update on the Essex statutory inquiry. In June, I told the House that the inquiry into NHS mental health in-patient facilities across Essex would move forward on a statutory footing. Today, I can announce that Baroness Lampard, who led the Department of Health’s inquiry into the crimes of Jimmy Savile, has agreed to chair the statutory inquiry. I know that Baroness Lampard will wish to engage with Members of the House and the families impacted, and following their input I will update the House on the terms of reference at the earliest opportunity.

The crimes of Lucy Letby were some of the very worst the United Kingdom has witnessed. I know that nothing can come close to righting the wrongs of the past, but I hope that Lady Justice Thirlwall’s inquiry will go at least some way towards giving the victims’ families the answers they deserve. My department and I are committed to putting in place robust safeguards to protect patient safety and to making sure that the lessons from this horrendous case are fully learned. I commend this Statement to the House.”

My Lords, the Statement that we consider today reminds us of acts that were so cruel that it is hard to make sense of them. Our thoughts must be with the families who have suffered the worst of ordeals and with the children who were so brutally taken from them. It can only be hoped that the conviction and the sentencing have helped bring some closure, even though the murderer dared not face up to them in person in court. More than this, the extent of the crimes committed by Lucy Letby may not yet be fully known, as Cheshire police have widened the investigation to now cover her entire clinical career.

There are heroes in this story—the doctors who fought to sound the alarm in the face of a hard-headed and stubborn refusal to even consider the evidence that was brought forward. I am sure that the whole House would wish to join me in recognising the courage of Dr Stephen Brearey and Dr Ravi Jayaram.

This killer should and could have been stopped months before. If it had not been for the persistent bravery of the staff who finally forced the hospital to call in the Cheshire police, the lives of even more babies would have been put at risk. The refusal to listen, the failure to approach the unexplained deaths of infants with an open mind, and the failure to properly investigate when the evidence appeared to be so clear, are absolutely unforgivable. There was then the insult of ordering concerned medics to write a letter of apology to a serial killer. It is clear that the allegations that were made and the evidence produced were not met with any respect or regard.

This is a tragic and true story, where events came together and flags were raised and ignored. It is to this point that I would like to take the Minister. I start by saying that we very much welcome that the inquiry has been put on a statutory footing, and it is welcome that the full force of the law will be behind it. However, can the Minister tell your Lordships’ House why it took so long to get to that correct decision? It is right that families have now been listened to, but why were they not consulted before the initial announcement? Will they be consulted ahead of any future decisions?

This is not the first time that whistleblowers in the National Health Service have been ignored. On all the occasions such as these where they have not been listened to, there has been a missed opportunity to save lives. The reality is that nobody thinks that the system of accountability, professional standards and regulation of NHS managers and leaders is good enough. Why were senior leaders at the hospital still employed after the conviction? Regarding the absence of serious regulation, which enables a revolving door of those with records of poor performance or misconduct, does the Minister agree that this is unacceptable, particularly when lives are at stake?

I refer the Minister to the duty of candour. It is 10 years since Sir Robert Francis’s report was published in which he put forward the duty of candour, and yet the duty of candour of a number of consultants was ignored and overridden in this case. As a result of that, will the Minister ensure that there is an independent external route through which concerns can be raised in future? Will he look at the accountability, scrutiny and supervision of clinicians throughout the National Health Service, because the pressures on the service at the moment mean that, sometimes, these vital double-checks can be missed? What review has been conducted into the effectiveness of the duty of candour? What is the conclusion of any review that has taken place about what has gone wrong over the past 10 years?

The terrible events at the Countess of Chester Hospital shine a clear light on a lack of consistent standards. Therefore, it is welcome that the Government are considering a register of NHS executives and the power to disbar, which was recommended by 2019 Kark review. However, the Government should go further. Will they begin the process of bringing in a regulatory system for managers, and standards and quality training, as was recommended by the 2022 Messenger review? Can the Minister indicate how and when there will be progress on bringing together a single set of unified core leadership and management standards for managers, and training and development to meet these standards? What is being done to promote excellence in leadership and to ensure patient support when things go wrong?

I am sure we can all agree—I know that the Minister will join with this—that we owe it to the children who lost their lives and to the families who grieve their loss to do what we can to prevent anything like this ever happening again.

My Lords, we have all been appalled at what happened at the Countess of Chester Hospital, and we would also like to extend our sympathy to all those affected, especially those parents of children who were taken from them. Those were losses that we now know that could, and should, have been prevented. I echo the comments of the noble Baroness, Lady Merron, in praise of those doctors who did raise concerns and fought to have them taken seriously. The accounts that we have seen of legitimate concerns either being ignored, or in some cases being actively suppressed, are truly shocking and represent a call to action that we must heed.

The inquiry is welcome, and will cover a lot of important ground, and I will not try to pre-empt their work today. Instead, I want to focus on one aspect where the department could act now without cutting across the work of the inquiry, and that is the role of NHS trust non-executive directors. This is something which the patient safety commissioner also highlighted in her statement on the Letby case. She said of NHS non-executive directors that

“it is vital that they are able to ask the right questions and escalate concerns where needed.”

The relationship between non-executive directors on a board and senior management teams in any organisation involves the delicate balance of responsibilities. Would the Minister agree that NHS trust non-executive directors should see patient safety as a priority responsibility—perhaps the single most important among their broad set of duties? Would he also agree that it is a healthy and positive situation if trust managers feel that they are under scrutiny from their non-executive directors on safety issues and believe that they will be pulled up if they are not fully open with them? We saw in this case claims of management not presenting the full sets of facts to their boards. They must be entirely candid with their non-executive directors and must expect to be challenged; that is the culture we want to see on trust boards, not one of cover-up and misleading.

In this context, could the Minister confirm whether the department will take steps now to reinforce with trust boards the importance of non-executive directors being able to raise safety issues? Importantly, will they be providing non-executive directors with training on how to perform this function effectively, so that they understand the best ways in which to challenge executives where necessary?

As I said at the outset, we welcome the inquiry from these benches, but I hope that the Government will not wait until the inquiry has completed its work to start making changes, and that they will be equally committed to making changes now where these would improve governance, and that the Minister can confirm that they are looking at strengthening the role of non-executive directors on NHS trust boards.

I would like to thank the comments, and the spirit of the comments, made by noble Lords. I start by adding my condolences to the parents and families in question. As we all know as parents, it is the most horrible thing we could ever imagine happening to us.

Clearly, the inquiry will find out the full facts of the matter, but at the same time it is important that lessons are learned quickly. To the point of the noble Baroness, Lady Merron, the families will continue to be consulted throughout this time. We would all agree that what happened is unforgivable, and we should praise the doctors for the work that they did and the courage that it took to bring it forward. I am convinced, as mentioned by the noble Lord, Lord Allan, that we need to make sure that we are doing sensible things in the meantime to ensure that we learn those lessons quickly. The foremost responsibility—the first line of defence as I like to call it—is the role of the board and the NEDs.

Speaking to colleagues about this, Chris Whitty was just saying that any sensible statistician and someone with sound common sense should have been able to say that there is something seriously awry here. We must all ensure that the boards are equipped to be able to challenge in the right way. That does take training, but it is important to make very clear to them that their primary duty must, beyond anything else, be the safety of the patients in that hospital. That has to be the first line of defence. There are things that we need to do to help them, including training—and to the noble Baroness’s point, that they are equipped with the records of those people so that it is known whether they are fit and proper people. One of the questions that I have asked, and got answered, is that I know there is a list so that, when you are looking to employ people, you know now whether a person is not a fit and proper person. As happened in this case, people moved on to other trusts in intervening periods, and there must be a mechanism where the trust can annually review, or review even more frequently, whether they are fit and proper through past cases that have just come to light, so that they have the ability to act.

It is our role to arm those boards, and give them the information and training to be that first line of defence. Tragically, we know in this case that first line of defence failed. These actions should bolster that first line of defence, but we also need to look at some of the second lines of defence. Medical examiners are a good way forward. From April 2024, they will now oversee all deaths that have not been put to coroners. I am told that this happens quite regularly already in the hospital setting; the challenge is more in the primary care setting. Along with other lines of defence, there is the duty of candour, allied with the freedom to speak up, so that we are gaining knowledge from the staff and people on the front line. Again, it is clear in this case that, while doctors were very brave in bringing it up, a lid was kept on it for too long. Clearly, we need to do more in terms of that whole approach of them feeling emboldened to speak up.

At the same time, the steps being taken in terms of the Getting It Right First Time programme and the health and safety investigations board and CQC are all good steps in that direction. But what is vital is that we do not, by putting in those central measures, somehow give boards the feeling that the first responsibility does not lie with them. It is the most important job that they can do, and the last thing that any of us would want is the feeling that they do not have to worry so much about that, because there are these other bodies looking into it. Absolutely fundamental to all of this is that they realise that it is their primary duty and that we in the centre are arming them to do that properly.

I hope that gives a good sense of the direction of travel we are going in, and I hope it accords very much with the points made. As to whether we should be going further in terms of registers to make that regulatory, we are absolutely open to that. It is just about trying to work out the practicalities and where the right level is. There are, however, some things, such as making sure this fit and proper persons list is up and running. That is something that we can do very quickly and are doing tomorrow. Clearly, there will be other opportunities for questions that I am taking in a moment. As ever, I will follow up all of this with a detailed reply. Most of all, I want to give a moment’s pause.

My Lords, I declare that I am registered with the General Medical Council. I am a doctor and I have been involved in providing some support to the Nuffield review into disagreements in care of critically ill children, which is about to report. As the noble Baroness, Lady Merron, pointed out, this is unbearably and unbelievably terrible. I watched the whole story unfold almost with a sense of disbelief, except the awful thing is that one can believe it happened as it did, with the suppression of the whistleblowers.

That is what I want to pick up from the point made by the noble Lord, Lord Allan: we do not have a senior doctor on every board. The training of a doctor is different from the training of a nurse, a manager or an HR manager. That understanding of statistics is different. When a doctor tries to raise a concern but hits a brick wall, they need to be able to go directly to another doctor on the board to explore what they want to raise and because that other doctor is also subject to the GMC’s requirements. I quote from the GMC’s duties of a doctor:

“You must take prompt action if you think patient safety, dignity or comfort is being compromised”—

“must” being the key word. It was easier for staff to raise issues in the days when there was a senior doctor on the board. It did not always work, but I hope the Government will look at that as an action that could be taken much more rapidly. The GMC also says that doctors must contribute to adverse event recognition.

Again, as has been pointed out, these things have happened before: we had the Robert Francis report into Mid Staffs and the Bristol inquiry into heart surgery. Those people who have been whistleblowers have been traumatised, but nobody has been as completely destroyed as the parents when they know that their child has been killed. Child bereavement is overwhelmingly terrible, but when you know that it was from the action of another person it is even more impossible to come to terms with it.

I hope the Government really will look at whether some urgent intermediate action can be taken, and whether they can have discussions with the GMC so that doctors who are reported to the GMC as being difficult because they are raising concerns are not treated with some of the problems that have arisen, where we have seen doctor suicides and so on when they have been inappropriately referred. I hope the Government will seriously consider whether there needs to be a senior doctor on every board, both in hospital and a provision in the community. Even the appraisal systems that are in place do not seem to be working adequately to protect whistleblowers.

I thank the noble Baroness for bringing her knowledge and skills to this. Bringing senior doctors very much goes along with the sentiment that we were all trying to express about equipping boards in the right way to be the first line of defence in bringing such things up. I know that many boards have doctors on them, but the noble Baroness raised a very good point; it is something that we should take back. From my point of view, I absolutely see the sense in making sure we do that.

My Lords, I also declare my interests as noted in the register, specifically as a previous Chief Nursing Officer for England and as a non-executive director of a number of NHS trusts for a number of years. I also extend my sympathy and prayers to those who have been impacted by these awful and unimaginable atrocities.

I join others in welcoming that this is now a statutory inquiry. I also support the points made by the noble Baroness, Lady Merron, particularly around NHS manager regulation. I ask the Minister whether, when the Government look at that regulation, they will consider that it should go beyond the NHS executive, who themselves are managers, so providing external scrutiny.

The NHS has sought to improve patient safety for decades. It has also sought to improve people’s ability to be whistleblowers through a number of reports— I was involved in the publication of some of them. There are policies, guidelines and NHS bodies. A number of policies are even referred to in the Statement, some of which are now up to eight years old. My question to the Minister is whether the review will look at why those policies, procedures and bodies that are already in place, with the aspiration of improving patient safety and enabling people to whistleblow, were not enough to prevent this. The question that goes alongside that is whether the review will look at culture. It is not just about the policies and procedures; what was the culture that enabled this to happen? How might we recognise it and prevent it happening again?

Again, I thank the right reverend Prelate for the sentiment of her reply. On whether we should be looking at the regulations beyond the executive, all these things are very much in the mix, for want of a better word, to ensure we have the right ones there. On the question of why the bodies that are in place did not catch it, obviously we will learn more as the inquiry goes along, but one of the major things for me when I looked at this was the fact that, because a lot of those cases did not go to a coroner, the medical examiner system was not fully in place at that point, so there was no other set of eyes in all that. I have to believe that if the medical examiners had looked at that they would have picked it up incredibly quickly. The fact that is now being put in place so that everything will have to be overviewed by a medical examiner or a coroner will be a key issue in all this.

There is an issue around the culture. I have a quote from a report by Sir Gordon Messenger, which is a perfect example on this and absolutely covers that point. It says that the culture that is set down by these places can often cause these problems. It is clear that, in the case of this hospital, the culture was not right. He said:

“We heard too frequently that poor inter-personal behaviours and attitudes were experienced in the workplace. Although by no means everywhere, acceptance of discrimination, bullying, blame cultures and responsibility avoidance has almost become normalised in certain parts of the system, as evidenced by staff surveys and several publicised examples of poor practice. This exists at the micro-level, in individual workplaces, and across sectors, where the enduring lack of parity of esteem, conditions and status between healthcare and social care remains a blight on effective collaborative working”.

That sums up a lot of the problem with the culture. The board, in terms of its training and equipment, is where staff surveys and feedback should act as one of the early warning mechanisms that we should look to put in place.

My Lords, I reinforce the points made by the noble Lord, Lord Allan, and the noble Baroness, Lady Finlay, about the importance of boards and patient safety being a key factor that they ought to take responsibility for. I will make a wider point. As health is a devolved matter and we are talking about the NHS in England, I urge the Minister to have comparisons of best practice: talk to the devolved Administrations, see what happens in Scotland, Wales and Northern Ireland, both for the way in which we can learn from each other’s experiences but also so we can arrive at common standards that can be accepted across the United Kingdom. Similarly, if any registers are being set up, these should not be confined to just England but should be UK-wide.

I thank the noble Baroness; that is a good point. We clearly need to be looking at best practice across the board. That is not limited to any one devolved authority, but means learning from each of them and, I think, somehow making sure that hopefully they can learn from the terrible events that have taken place here—so they are putting that in place as well. For me, one of the main failings that we are now putting right is the medical examiners, which I want to make sure are spread out across all the devolved authorities. Clearly it is up to them whether they take it or not, but we should absolutely be making sure that we are cross-fertilising some of those key learnings, so they go both ways.