The Observer view: only a robust inquiry will hold NHS to account over Lucy Letby murders | Observer editorial

The murder of premature babies in their first few weeks of life by a medical professional is impossible to make sense of. But this is the crime of which Lucy Letby, a nurse in the neonatal unit at the Countess of Chester hospital, was last week convicted in relation to a number of vulnerable infants entrusted to her care. They were utterly dependent on the clinical staff in that unit. But Letby murdered seven babies, attacking some multiple times before she succeeded in killing them. She has also been convicted of the attempted murder of another six, two of whom have been left with brain damage as a result.

This makes Letby Britain’s worst child killer of modern times. She used a variety of means on her victims, including administering fatal injections of air, poisoning with insulin, overfeeding with milk and tampering with feeding tubes. The police have now begun the task of investigating the records of more than 4,000 babies across two hospitals whose care may have been tampered with by Letby. The critical question that needs answering now the criminal trial is concluded is how she was able to get away with these crimes over the course of more than a year and why some of these murders were not prevented after senior clinicians repeatedly raised red flags about their suspicions. A full assessment of how their babies were fatally let down by the system is the very least the families are owed.

The government has announced an independent inquiry into how the Letby murders were handled by the Countess of Chester hospital, but has so far declined to put it on a statutory footing. This is not good enough. The criminal trial and the reporting around it have highlighted evidence of grievous failings by the NHS trust that runs the hospital, but no one from hospital management was required to give evidence in the trial. It is of vital importance a statutory inquiry is given the power to summon evidence and force witnesses to testify, to examine not just the actions of the trust and its employees but other agencies involved in the events that unfolded, including the Care Quality Commission.

In particular, the inquiry must ask why no investigation into these unexplained baby deaths was ordered by hospital management until July 2016, more than a year after doctors first raised concerns. Two reviews in the second half of 2016, one by the Royal College of Paediatrics and Child Health and the second by a premature baby expert, recommended a thorough external independent review of each neonatal death and further forensic investigation; neither of these things happened. The senior management team did not keep the trust’s board informed of the findings of the reviews that had both called for further investigation; minutes show executives said the reviews concluded the issues were down to the unit’s leadership and timely intervention.

The hospital took a full year to remove Letby from the neonatal unit after suspicions were first raised, and members of its senior executive team are alleged to have claimed that the two reviews cleared Letby and said they would be moving her back to frontline work on the neonatal ward. In the interim, she was moved to the hospital’s risk and patient safety office where, despite the fact she was under suspicion of being associated with unexplained infant deaths, her role included raising serious incident investigation reports to the NHS.

The catalogue of failings does not stop there. It was a small group of consultant whistleblowers on the neonatal unit who played a key role in flagging their concerns; it is not clear that without them these crimes would have come to light, as the deaths were not properly reported to the NHS and so not picked up by its alert systems. Yet they were treated appallingly by hospital management: their calls for urgent meetings went unheeded; their concerns were treated dismissively and they say that once management had decided Letby should return to her post in 2017, two of them were instructed to enter a mediation process with her. They were warned her father had threatened to refer them to the General Medical Council unless they withdrew their allegations and were asked to write a letter of apology to her. The medical director who started in 2018, and who later became the chief executive of the trust, says she was warned by her predecessor that she would need to pursue action with the GMC against the whistleblowers (something he denies).

What we know so far about this truly awful case throws up familiar themes that crop up again and again in scandals that have in recent years beset failing NHS trusts, from mid-Staffs where hundreds died as a result of poor care at Stafford hospital, to the several maternity scandals that have emerged. Defensiveness in management culture; appallingly punitive treatment of whistleblowers; prioritisation of the reputation of a hospital over patient safety and dignity: the evil acts of Letby may thankfully be “exceedingly rare”, according to experts, but we have seen time and again how these toxic cultures produce avoidable deaths, injury and heartache for patients and families. In this case, it seems highly likely that failings by this hospital contributed to the preventable murder of babies. That would be a devastating verdict, and it is only right that the question of who is responsible and how this could have happened is handed to a statutory inquiry with the powers it needs to provide answers.