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Gwyn Bevan

September 4th, 2023

Lucy Letby – another case of regulatory failure in the NHS

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Estimated reading time: 6 minutes

Gwyn Bevan

September 4th, 2023

Lucy Letby – another case of regulatory failure in the NHS

0 comments | 7 shares

Estimated reading time: 6 minutes

The unprecedented crimes committed by Lucy Letby whilst working in the NHS have provoked widespread shock and anger. Gwyn Bevan considers how this case compares with previous systemic failures in responding to NHS scandals. He argues that these are consequences of NHS systems that were designed to fail and that we need to go back to the principle of Ministerial Accountability.


To paraphrase Tolstoy, all high-performing healthcare systems are alike – each one fails scandalously in its own way.  Lucy Letby, Britain’s worst child serial killer, has been found guilty of killing seven babies and attempting to kill six others when working in the neonatal unit at the Countess of Chester NHS Foundation Trust between June 2015 and June 2016. Letby is a psychopath, like Britain’s worst serial killer, Harold Shipman, a GP who murdered over 200 of his patients. Unlike Letby, he escaped scrutiny from clinical colleagues by working as a single-handed GP. The Letby case reopens the book on how patient safety can be guaranteed within the NHS and is to be the subject of another statutory inquiry.

Do no harm

In 1863, Florence Nightingale observed that: “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm”. The Countess of Chester is yet another scandal where NHS hospital managers continued to violate Nightingale’s first requirement and instead aimed to suppress courageous whistle-blowers. In How Did Britain Come to This?, my forthcoming book on a century of systemic failures of governance, I discuss two previous statutory inquiries into the NHS, which were the subject of the 2001 Kennedy Report and the 2013 Francis Report.

The Kennedy Report estimated that, between 1991 and 1995, there had been about 30 excess deaths at Bristol Royal Infirmary (BRI) from children’s heart surgery (as compared with other centres). The report identified two systemic failings of governance. First, the decision to choose BRI for special funding as centre for children’s heart surgery on grounds of geography, despite its inappropriateness. Second, there was no body responsible for regulating quality of care in the NHS and confusion over which organisation ought to act on known failings at Bristol.

The Francis Report described appalling neglect of patients at the Mid-Staffordshire NHS Foundation Trust from 2005 to 2008: patients were left in excrement-soiled bed clothes for lengthy periods, not given the help they needed for eating or toileting, treated with callous indifference, and denied privacy and dignity, even in death. Over that period, the Healthcare Commission (HCC) was responsible for regulating quality of healthcare in the NHS (and the independent sector) in England. For 2006–07, HCC rated quality of care at Mid-Staffordshire as “fair” and as one of the four “most improved acute and specialist trusts”.

HCC was eventually alerted to the scandal at Mid-Staffordshire because of its 500 excess deaths (from 2005 and 2008). The Francis Report pointed out that HCC was “the first organisation out of the plethora with relevant responsibilities to identify serious cause for concern, and to take the action which led to the full exposure of the scandal”. Yet it had also “failed to prevent or detect over three-quarters of its lifetime what has been described as the biggest scandal in NHS history”.

The Care Quality Commission (CQC) is currently responsible for regulating quality of health care and social care in England. The Guardian reported that when CQC inspected the Countess of Chester NHS Foundation Trust, in February 2016, they told the medical director that senior consultants felt that they had been ignored  when they had raised patient safety concerns with senior management. CQC’s 2016 Report rated the Trust’s services for children and young people as “good”. CQC found “that incidents were being reported and that information following clinical incidents was fed back to staff in daily safety briefings”; and “the majority incidents at the Trust were of low or no harm to patients, were reported appropriately, and lessons were learned and shared with staff”. In the neonatal unit, the problems CQC identified were from insufficient staffing levels and a lack of storage space and equipment; but not from the number of babies collapsing or dying on the unit.

The problems CQC identified were from insufficient staffing levels and a lack of storage space and equipment, not from the number of babies collapsing or dying on the unit.

Securing enduring reform

From 2000 to 2003, I worked for the Commission for Health Improvement (CHI). Our primary role was to report on our reviews of the implementation of systems of clinical governance in the NHS in England and Wales, systems that aim to assure and improve quality of care. In practice, the challenge for our review teams was to find a dysfunctional clinical team in each Trust they visited: there was typically one, which the managers knew about, but failed to act until CHI spotted it.

Hence my three thought experiments: If it had been CHI that inspected Bristol in the 1990s, Mid-Staffordshire in 2006, and Countess of Chester in 2015, would we have discovered the scandals there? At the BRI and the Countess of Chester, we would not have done so from our analyses of routinely available statistical data at the hospital level, because the numbers of excess deaths were so small.  The only way we would have found out was from two serendipitous elements of the CHI’s inspections. First, reports to the CHI’s staff at publicly organised sessions where parents and local GPs would have been able to voice their concerns in confidence. Second, the week’s visit by the CHI’s review team offered safe opportunities for whistleblowing by the staff members who were troubled by poor quality of care and bad outcomes. The first would have made clear problems at Bristol and Mid-Staffordshire and the second at the Countess of Chester, so why did HCC and CQC fail?

Clinical governance reporting was a daunting but feasible task for CHI. In 1999, before CHI began, a paper by Kieran Walsh presciently suggested that Ministers would not be satisfied with reports on clinical governance, but would want instead “performance” reports on hospitals like those from OFSTED on schools. And HCC and CQC have been required to give assessments across the different services provided by NHS Trusts. Unfortunately, as I argued in a 2006 paper with Jocelyn Cornwell, that is mission impossible.

Herman Wouk’s Caine Mutiny described the US navy as: “A system designed by a genius to be run by idiots”. Even if they were run by geniuses, England’s regulatory systems are designed to fail for the NHS (and water, railways and energy). The obvious remedy is to return to the quaint tradition of ministerial accountability, which Aneurin Bevan saw as fundamental to the governance of the NHS. Before its inception on 5 July 1948, the Times reported a speech in which he expected this to mean that, “echoes would reverberate throughout Whitehall every time a maid kicked over a bucket in a hospital ward”.


Gwyn Bevan’s new book, How Did Britain Come To This? A century of systemic failures of governancewill be published by LSE Press in October 2023 and will be freely available to read download via Open Access publishing. Subscribe to the LSE Press newsletter for further details on the book’s release.

All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science.

Photo credit: Featured image by Shutterstock, main image by Damien Walmsley, Creative Commons — Attribution-NonCommercial 2.0 Generic — CC BY-NC 2.0

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About the author

Gwyn Bevan

Gwyn Bevan

Gwyn Bevan is Emeritus Professor of Policy Analysis in the Department of Management at LSE and author of How did Britain come to this? A century of systemic failures of governance.

Posted In: Governance | LSE Comment | Public Services and the Welfare State
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This work by British Politics and Policy at LSE is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported.