Intended for healthcare professionals

Rapid response to:


Letby’s killing spree raises questions over NHS governance

BMJ 2023; 382 doi: (Published 22 August 2023) Cite this as: BMJ 2023;382:p1931

Linked Opinion

Lessons not learned

Rapid Response:

Lack of parity in oversight or response

Dear Editor

We agree with Dyer [1] that the crimes committed by Lucy Letby raise important questions about how concerns and variations in clinical outcomes are responded to. This is particularly pertinent as routine checks and balances did not identify that the mortality exceedance in the neonatal unit was of very high statistical significance.

We argue that this case shines a spotlight on the lack of parity in oversight or response for local variations in clinical outcomes for Non-Communicable (NCD) or non-infectious diseases in comparison to communicable disease (CD) control [2]. If the unexpected deaths on the unit had been thought to be due to an infectious disease -- for example, MRSA, C-Diff, or even Covid-19 -- health protection colleagues would have become aware through notifications or routine surveillance. A response would have been initiated in June 2015 and a multiagency incident investigation instigated [3]. Resources would have been mobilised and standardised, legislated [4] [5] consensus of what constitutes an outbreak (including investigative steps and methodologies for defining and identifying linked cases) would have provided a structured means to explore and address or dismiss the excess mortality concerns [2]. Whilst cognisant of the cultural issues at play in this case, a comparable response in this situation could well have prevented these awful and protracted crimes from happening again and again.

Establishing parity of response for local variations in NCD outcomes and CD control is critically important. “Collective local whole health economy response, exploiting the wealth of surveillance data in real time, needs to be at the heart of responding to variations” [2]. This view chimes with that of other experts including Dr Kirkup who told the BBC we need “to see better systems for tracking patient outcomes put in place” [6].

We believe that national and local health agencies should mandate a standardised ‘incident’ response to significant changes in outcomes to mitigate and reduce the loss of quality life [2]. As NHS staff or advisers, we are committed to making this approach a reality.

[1] Dyer, C, "Letby’s killing spree raises questions over NHS governance," BMJ, vol. 382, p. 1931, 2023.
[2] Knight, J., Day, M., Mair-Jenkins, J., Bentley, C., Anderson, B., and Khaw, F-M, "Responding to sustained poor outcomes in the management of non-communicable diseases (NCDs): an “incident control” approach is needed to improve and protect population health," BMC Public health, vol. 580, 16 May 2019.
[3] UK Health Security Agency, "Managing outbreaks and incidents," GOV.UK, 28 July 2023. [Online]. Available: [Accessed 22 August 2023].
[4], "Public Health (Control of Disease) Act 1984," 20 August 2023. [Online]. Available: [Accessed 22 August 2023].
[5], "The Health Protection (Notification) Regulations 2010," [Online]. Available: [Accessed 22 August 2023].
[6] BBC News, "Lucy Letby: How could the NHS stop a future killer within?," 21 August 2923. [Online]. Available: [Accessed 22 August 2023].
[7] World Health Organisation, "International Health Regulations (2005)," 1 January 2008. [Online]. Available: [Accessed 22 August 2023].

Competing interests: No competing interests

24 August 2023
Julia M Emery
Consultant in Public Health and NIHR Doctoral Fellow
Benjamin Rush, Chris Bentley
University of Nottingham
Clinical Science Building, City Hospital, Hucknall Rd, Nottingham, NG5 1PB