The weekend papers and TV have raked over the Lucy Letby story and the machinations at the Countess of Chester Hosptial.
The Department of Health have announced an inquiry. The speed of the announcement tells you about the significance they are attaching to it.
Steve Barclay says the terms of reference will be influenced by the parents. The chair, to be announced.
It’ll not be a public inquiry. However, as there is no shortage of people who are willing to give evidence, I think speed trumps legal palaver.
The chief executive (at the time) Tony Chambers has already indicated he will give evidence and this is a statement from him that you should read.
The longest murder trial in UK history. This excellent HSJ time-line, tells informed NHS watchers, no inquiry is really necessary. You could write the report now, in a paragraph…
‘Trust management ignored early warnings. Whistleblowers were humiliated, threatened with disciplinary action, their professional registration put in jeopardy. The Trust’s management culture was blinkered, oppressive and bullying. There are lessons to be learned.’
Letby is the case no one wanted to believe was true. That was the problem. Along with the un-holy trinity of;
- cognative bias,
- confirmation bias and
- group think.
Letby was reliable. A popular member of staff. Referred to by one witness as ‘Nice Lucy’… well regarded, no disciplinary or complaints history.
She went on to work with management and was familiar with them and to them.
Reputation management is upmost in most manager’s minds. The first whiff of a problem… the instinct is to circle the wagons.
Don’t let NHSE’s regional apparatchiks anywhere near it. Keep the press away and heaven forfend… the police.
The CQC were irrelevant. There were reports in 2013, then a three year gap to 2016, then 2018 and 2022. They weren’t great reports so Trust managers would know the inspectors needed to be kept away.
There was no whiff of a scandal…and…
… the trinity;
First, cognitive bias.
The tendency for us all is to form judgements through a thought process that simplifies our thinking about information through the filter of our personal experiences.
Child murders of this type are very rare, only 16 globally, ever. Lucy is very nice. It can’t be right. Not here.
Second, confirmation bias.
As evidence mounts we dig a deeper hole. Just as airline pilots form an incorrect mental model of their situation and have a very difficult time changing that view, even in the face of new information and crash the plane… it’s how managers crash organisations.
Disbelief of the evidence. Serial killing in hospital, of young children, impossibly rare and Lucy is very nice.
As complaints mount and more managers are involved…
Third, Group think.
A Board, reaches a consensus without critical reasoning or evaluation of the consequences or alternatives.
Groupthink, based on a common desire not to upset the balance of a group of people. Lack of challenge from non-exec’s and chair is a very common example.
Mass murder cannot be happening here. Managers are having a difficult time managing bizarre allegations, we must support them.
The Chair at the Countess, at the time was Sir Duncan Nichol, former boss of the whole NHS. He says the Board were misled by managers.
I say, it was the Board’s job to ensure they were not misled by managers. Ask; why, what, really, show me, prove it, tell me again, how, if, what about?
A Board is not a showcase or a club. It is an engine room, a test bed and a proving ground.
Put those three killer components together and you can see why it is; all the ‘speaking-up’ guardians, red-flags, Patient Safety Incident Response Frameworks, well-led frameworks , medical examiners and never event blah, blah will ever trump human behaviour.
Are there things we could change? Yes, four.
1.Reframe the NHS.
We are a fix-you-up service full of compassion and love. We should realise we are a safety critical industry, full of compassion and love.
Change the mind set from the first day of training. Safety trumps everything and every one has to know that.
Everyone has to know; it is safe to ask about safety and dangerous if we don’t.
2. Internal safety complaints.
If two or more consultants raise a safety critical issue, management must be obliged to call in a consultant from an adjoining Trusts to have a look.
If necessary, make recommendations and cary them through.
Make the learning available to everyone.
3. The role of post-mortem.
They are not routine. They are at the behest of the coroner or the request of the hospital with the consent of the family.
They did not raise alarms in this case and the whole approach and technology might benefit from a review.
I’m not an expert but an expert will know why an overdose of insulin wasn’t picked up. Can we fix that?
4. No fault management and systems.
In Sweden and New Zealand they realise error and failure are inevitable. They look for problems differently and not for fault.
They work on the principle of no-fault. What’s gone wrong is separated from how do we put it right…
… designed to lead to learning and understanding.
Our systems are based on fault. Who is at fault? Our regulation based on threat… of prosecution, disgrace and the end of a career…
… designed to lead to cover up.
Few reports are ever implemented in full. Many sit on a shelf.
Let’s make this one the one that makes the change, to make the changes.
News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.
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