The British government has ordered in inquiry into the killing and attempted killing of more than a dozen babies by a nurse in the north of England.
On Friday, neonatal nurse Lucy Letby, 33, was found guilty of murdering seven newborn babies and attempting to murder another six at the Countess of Chester Hospital between 2015 and 2016.
The independent inquiry has been “launched to ensure vital lessons are learned” and to probe the “wider circumstances around what happened,” according to a government statement.
It will look not just at the handling of warnings at the Cheshire hospital where the deaths took place, but at “what actions were taken by regulators” and the wider public health system.
The move comes amid criticism that Ms Letby was able to evade formal scrutiny as the hospital’s infant mortality rate rose and suspiscions were raised about her activities.
British news outlets have catalogued numerous “missed opportunities” for earlier intervention in the case.
A lead consultant at the hospital told the BBC he’d warned hospital management about Ms Letby back in October 2015, but said his concerns fell on deaf ears.
Leaders resisted his attempts to take her off duty in June 2016 and instead transferred her to the hospital’s patient safety and risk office.
A July 2016 internal review into a sharp rise in mortality described higher levels of patient acuity, more activity on the ward and low staffing numbers, according to industry outlet HSJ. It did not raise concerns about Ms Letby or any other members of staff.
A further report by the Royal College of Paediatrics and Child Health raised similar themes, and did not find Ms Letby to be of concern.
At one point, trust leaders criticised consultants for suggesting Ms Letby was linked to baby deaths. She had filed a grievance against suspicious staff members and, according to documents seen by HSJ, management considered her transfer off the ward to have been “orchestrated by the consultants with no hard evidence.”
Police began investigating rising infant mortality rates in the spring of 2017, and arrested Ms Letby in July 2018.
Senior investigating officer, Cheshire Police’s Detective Superintendent Paul Hughes, said staff had called surge of deaths and near-deaths “unexplained and unexpected” in an interview with the BBC.
The government inquiry will consider how staff concerns were dealt with, among other circumstances surrounding the murders and attempted murders.
It will be non-statutory, so will not have the power to compel witnesses or summon evidence: a decision criticised by some lawmakers. But the government says this style of inquiry will “focus on lessons that can be learned quickly.”
Health and Social Care Secretary Steve Barclay said he was “determined” the voices of affected families would be heard and that they would be “involved in shaping the scope of the inquiry should they wish to do so.”
“It will help us identify where and how patient safety standards failed to be met and ensure mothers and their partners rightly have faith in our healthcare system,” he added.
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