Intended for healthcare professionals


Lessons not learned

BMJ 2023; 382 doi: (Published 23 August 2023) Cite this as: BMJ 2023;382:p1943

Linked News

Letby’s killing spree raises questions over NHS governance

  1. Alison Leary, professor of Healthcare and Workforce Modelling
  1. London South Bank University

In the wake of the conviction of Lucy Letby, a neonatal nurse who has been found guilty of the murder of seven babies and attempted murder of six babies, the focus of the nation is on the multiple tragedies that the families have faced, the healthcare staff who tried to blow the whistle, and safety issues in hospitals.

NHS England has responded to the conviction by stating that trusts should look at whistleblowing policies, that those unfit to hold directorships should not be appointed, and with that well worn phrase “lessons will be learned.”1 But will they?

We see the same issues emerging here that we have seen many times in the past 50 years’ worth of patient safety inquiries. Frontline staff have concerns ignored or suppressed, NHS Trust boards appear more concerned with potential reputational damage and financial performance than quality of care, growing staff shortages, a leadership apparently lacking in courage and integrity, and claims of an aggressive workplace culture.234 Although the malign influence of murder was the cause of deaths at the Countess of Chester, these reactions to patient safety issues could have been found in many inquiries of the last 50 years. So why are no lessons learned?

Unlike other safety critical industries, healthcare is still wedded to concepts that effectively deny the complexity of work and the social structures that surround work.5 We see this in the entrenched belief placed in approaches like root cause analysis as the solution to issues with no one root cause, an outdated Christmas tree model of workforce that promotes a hierarchy of value of work, and the employment of lower cost workers rather than retaining experienced ones. Most healthcare organisations have power gradients, and the formal and informal structures are hard for individuals to navigate. It can be challenging for individuals to have a voice of influence.6 Often there is a lack of a robust safety infrastructure such as a safety management system.7 The emphasis is also usually on the workforce speaking up, which in the current system requires courage, but perhaps the emphasis should be on listening. A safety officer in a large nuclear installation once told me that if people need courage to come to work, something has gone badly wrong.

When workers are listened to and constructive dissent is encouraged and normalised, along with the reporting of incidents, there is little need for whistleblowing. A workforce that must resort to whistleblowing is a symptom of poor safety culture.

“Success” in healthcare is measured by how much work is done, not how well work is done. This sets up a competing priority between those responsible for performance of the system, usually Trust boards and arm’s length bodies, and those responsible for delivering the care. Essentially, activity has priority and safety in healthcare is not income generating.8 Aside from the criminal convictions, the lower profile cases that only make the local news tell a story of “bad apples” being tolerated due to the demands of long waiting lists.9 Until this conflict of interest is resolved, those using their voice to raise concerns will likely be met with indifference or risk their livelihoods.

Safety is a board responsibility, but there is still a question of accountability. The actions or inactions of leadership have come up frequently in inquiries. The Kark review in 2019 recommended a register for healthcare managers and disbarring in cases of serious misconduct, however this was rejected by the Secretary of State for Health and Social Care.1011 It makes it possible for poor performing leaders to move around the system and even fall upwards into positions of influence, perpetuating the same issues.

Lucy Letby has been convicted and sentenced to life in prison, but questions remain, can any organisation be assured with its current systems, processes, and culture that, even if the intention is not malign, it will detect and act on potential harm to patients?


  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: commissioned, not peer reviewed.