Letby Inquiry Hears NHS Duty of Candour Is “Not Working” Due to “Puny Fines”

The public inquiry investigating Lucy Letby’s offenses has been informed that “puny fines” imposed on NHS organizations for failing to uphold their duty of candour with patients result in “no deterrent”. According to a former senior ombudsman, this indicates that the legal requirement for openness and transparency with patients and their relatives, referred to as the duty of candour, is “not working in the NHS”. Sir Rob Behrens, who served as the Parliamentary and Health Service Ombudsman from April 2017 until March 2024, provided testimony to the Thirlwall Inquiry. This inquiry is scrutinizing Letby’s homicides of infants at Countess of Chester Hospital. He stated: “It doesn’t work because it doesn’t apply to individuals, it applies to persons and that is interpreted as a public body.” He further elaborated: “Secondly, the fines issued are so puny that it doesn’t have impact on the behaviour of the leaders of the (NHS) trust.” He added, “Time and time again, we have seen senior managers and boards are more interested in preserving the reputation of their organisation rather than dealing with patient safety issues.” Sir Rob also noted that existing whistleblowing legislation in England was ineffective, as medical professionals were apprehensive about jeopardizing their careers by speaking up. He mentioned that Freedom to Speak Up Guardians – staff members specifically appointed to assist individuals in voicing concerns within the NHS – performed a “brilliant job,” but some of these guardians had confided in him that they themselves felt unable to be candid and open about their own experiences, fearing disciplinary action. According to Sir Rob, certain leaders of NHS trusts had accused investigators or whistleblowers of “undermining” them. He asserted, “You have to acknowledge where things go wrong”. He further commented, “One of the great things that I have learnt as ombudsman is the heroic behaviour of parents and family members in seeking to keep cases going which otherwise would have fallen by the wayside, and that should not be the case.” The inquiry was informed that no grievances concerning patient care at the Countess of Chester’s neonatal unit were lodged with the ombudsman during 2015 and 2016, the period when Letby assaulted infants under her supervision. Following the fatalities of two triplet boys in June 2016, consultant paediatricians communicated their concerns to hospital management that the nurse was intentionally harming babies; however, law enforcement was not contacted until May 2017. Tony Chambers, the former chief executive, has refuted allegations that he attempted to “ruin the careers” of medical professionals Dr Ravi Jayaram and Dr Stephen Brearey after they brought these concerns to his notice. Letby, aged 34 and originating from Hereford, is currently serving 15 whole-life orders. Her conviction at Manchester Crown Court was for the murder of seven infants and the attempted murder of seven others, including two attempts on a single victim, which occurred between June 2015 and June 2016. The inquiry, which is convening at Liverpool Town Hall, is scheduled to hear testimony until January, and its conclusions are anticipated to be released in autumn 2025.