Intended for healthcare professionals

Opinion Taking Stock

Rammya Mathew: Lucy Letby and the limits of a no blame culture

BMJ 2023; 382 doi: (Published 29 August 2023) Cite this as: BMJ 2023;382:p1966
  1. Rammya Mathew, GP
  1. London
  1. rammya.mathew{at}
    Follow Rammya on Twitter: @RammyaMathew

The dreadful reality of the Lucy Letby case is still sinking in. That a neonatal nurse was murdering babies under her care and attempting to harm more is hard to comprehend. But so is the fact that healthcare professionals raising concerns that Letby may have been behind these deaths were silenced and, worse still, were accused of bullying and threatened with referral to the General Medical Council. As the headlines hit the newspapers, colleagues talked about how the case was both shocking and unsurprising in different ways. Murders in healthcare are thankfully very rare, but the questionable way in which concerns are managed is something most NHS staff have witnessed in abundance.

The NHS has many excellent managers who go out of their way to ensure that services are well run and that staff are treated fairly, to whom good patient care matters as much as it does to practising clinicians. But equally, I regularly see a failure to acknowledge or listen to clinicians’ concerns, power struggles between clinicians and managers, and interprofessional divides—all of which can stand in the way of the right thing happening for patients and staff.

Much of this stems from a top-down culture in NHS trusts, where senior managers are desperate to protect their reputation, and managers further down the hierarchy can feel pressure to keep up appearances that all is well—even when it isn’t. Whistleblowers become an inconvenience in this culture, and efforts become unduly focused on how to shut down the whistleblower rather than confronting the problems raised. Even when problems are formally investigated, internal reviews are often felt to lack independence.

The Letby case is an extreme example of the shortcomings of a “no blame” culture. When things go wrong we’re encouraged to always support staff and ensure that no one feels implicated. It’s as though only systems and processes can be criticised, and discussing the possibility of individual accountability is considered “off grounds.” This case highlights why we can’t assume that every healthcare professional is “good”—be it morally, in terms of their integrity, or professionally, in terms of their skills and competence. When concerns are raised, as clinical managers we do have to look after the wellbeing of our staff, but our ultimate responsibility is to review the evidence and ensure that the right actions are taken—not to turn a blind eye because it would look bad or hurt someone’s feelings.

I am, however, conscious that the dialogue around the Letby case could unintentionally deepen the rift between managers and clinicians, which would be a disastrous outcome. I hear and recognise the concerns of the profession. The existing interprofessional divides in the NHS all need to be fixed, but that won’t be done by castigating managers.

We need to reform organisational culture so that managers and clinicians work more symbiotically, raising concerns is expected and welcomed, and managers feel able to make tough decisions based on the evidence, without worrying about reputational damage or breaching a “no blame” policy. This is likely to be a 10 year journey and not the tick box exercise that most NHS trusts will engage in off the back of NHS England’s communication asking them to review their whistleblowing policies. We owe it to the families affected to do better than that.


  • Competing interests: None.

  • Provenance and peer review: Commissioned; not externally peer reviewed.