Individuals and organisations cannot plan for the truly extraordinary. When a once in a millennium event occurs there is a high chance that people will react badly and make mistakes. The deliberate killing and injuring of children in a British hospital by nurse Beverley Allitt was just such an event,1 and many mistakes have been made in the aftermath.

But for the diligence of the two consultant paediatricians, Drs Nelson Porter and Charith Nanayakkara, at Grantham and Kesteven Hospital Beverley Allitt would probably not have been convicted of murder. Now, however, nine months after she was convicted of killing four children and injuring nine more in the children's ward of Grantham and Kesteven Hospital,1 the two consultants are without their jobs. They also fear criticism from the Clothier inquiry, set up by the secretary of state for health into the circumstances of the murders and due to report next week. The consultants have not had a chance to defend themselves in public. Because of the decision to hold the Clothier inquiry in private, health service employees and the public cannot be sure that all the lessons that might have been learnt will be learnt. And, worst of all, services for children in Grantham have been diminished.

In an environment such as a children's ward, …