The public inquiry into the Lucy Letby case may have reserved the strongest criticism for the Countess of Chester Hospital and its management, but there are big questions for the wider NHS to answer too. The Thirlwall inquiry's final report said there was a "complete failure" to protect babies on the neonatal unit where Letby murdered seven and attempted to murder seven more. But a third of the report was given over to the wider role played by the health system in England - and make no mistake, it was found lacking.
Across more than 200 pages, inquiry chair Lady Justice Thirlwall set out how the culture of the health system created the conditions that enable poor care - or in this case criminality - to go unchecked for so long. The failures encompass everything from regulation and employment practices to the way the NHS and government struggle to learn the lessons of the past. They have prompted Health Secretary Yvette Cooper to say she "will not hesitate" to hold the system to account at every level.
She has promised to set up a hub to track the progress on implementing the inquiry's recommendations and pointed to the creation of a new maternity and neonatal commissioner post as a sign of her commitment to improving standards. "This must be a turning point for the NHS," she told the House of Commons when responding to the publication of the report. The inquiry said NHS managers have become pre-occupied with avoiding blame, leading to an "over-focus on process and reputation management".
One witness described this as "blame engineering", with the inquiry concluding this was a key characteristic in the way Countess of Chester bosses approached the Letby case with the report describing it at one point as an "exercise in spin". This approach to management means raising the alarm becomes difficult - a concern that has been repeated again and again in inquiries into other scandals. There have been plenty of initiatives to address this over the years.
In the last decade, this has taken the form of the Freedom to Speak Up programme with each NHS organisation having a "guardian" whose job is it to support staff who want to issue a concern. But in a number of places the initiative has become a "box ticking" exercise The result? A "toxic negativity" persists around whistleblowing with staff discouraged from speaking out, the inquiry said.
This view is supported by the NHS staff survey which showed a declining confidence in speaking out. There is, the Thirlwall inquiry said, a consistent inability within the NHS to deal with poor performance. Failing managers will be moved, often with the active assistance of NHS England, in a process referred to as rehabilitation, the inquiry heard.
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