Cowper’s Cut 448: Public inquiry fatigue hits the Thirlwall
The Thirlwall Public Inquiry Report into the neonatal deaths currently regarded as murders by nurse Lucy Letby at the Countess Of Chester NHS Hospital between 2015 and 2018 arrived with a phrase that needs reading carefully: “at the time of these events, the neonatal unit was cramped and outdated, had repeated problems with the plumbing and lacked facilities for mothers to stay with their babies. It was very inconveniently located on a different floor from the post-natal ward.”
It is worth recalling that evidence given at Letby’s 2023 trial included sewage backing up into the handwashing sinks in the neonatal unit.
The Report also states,
“The number of deaths against the number of admissions each year was:
- 2010: 1 death; 422 admissions
- 2011: 3 deaths; 514 admissions
- 2012: 3 deaths; 556 admissions
- 2013: 2 deaths; 460 admissions
- 2014: 3 deaths; 557 admissions
“In 2015, eight babies out of 468 admissions died on the neonatal unit. In addition, two other babies born at the Countess were transferred to other hospitals, where they died. Three of the eight babies who died at the Countess were babies in respect of whom no charges were brought against Letby. Two of them died from severe congenital abnormalities. The third died from prematurity with sepsis. Letby was charged with and convicted of murdering the other five babies: Baby A, Baby C, Baby D, Baby E and Baby I.
“There were 496 admissions to the neonatal unit in 2016. In the first six months, five babies died. Three babies who died in January, February and March all died from congenital abnormalities. No charges were brought against Letby in respect of these deaths. Letby was charged with and convicted of murdering the other two babies – Baby O and Baby P, two of three triplets – in late June 2016 … If the babies whom Letby was convicted of murdering were removed from the annual number of deaths in the neonatal unit, the mortality figures for the Countess would be three deaths in 2015 and three deaths in 2016, broadly consistent with previous years.
“Since July 2016, there has been one death on the neonatal unit, in September 2019.”
When assessing the Thirlwall Inquiry Report, we need to keep all of this in mind. Obviously, tragic medical events can be concentrated in number by sheer random scatter. Other explanations are also available.
Alastair McLellan
Health Service Journal editor Alastair McLellan disliked the Report a lot, as his coruscating editorial shows. He describes “a summary and a set of recommendations, many of which are patronising, unrealistic, often confusing and – in some cases – plain ignorant”, and argues a good case for the many weaknesses in the Report’s arguments. It adds force to his previous comments about public inquiries’ lack of value.
The national media response was to focus on the Inquiry’s conclusions about NHS managers, which appear to generalise widely and wildly from the particular of particularly poor behaviour by the incumbent COC management at the time of the deaths.
The Report concludes that then-CEO Tony Chambers’ “intention throughout was to stall or obstruct a police investigation and he had succeeded for almost a year.” It also describes the management’s lack of candour towards families from the trust as “lamentable … even when the police were brought into the hospital in 2017, they were not aware of it. For most, the first they knew that the deaths of their babies may not have been from natural causes was at the time of Letby’s arrest in June 2018.”
Thirlwall describes “dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals of safeguarding … it was inescapable that there is a culture [in NHS management] of avoiding dealing with poor performance … This state of affairs is accepted with almost a collective shrug of senior shoulders. It should not be tolerated.”
The report goes on to say that “managers need to understand what people in the hospital actually do”. Mmmmmmm. It is very far from clear that the events at the COC were in any way caused by this deficiency.
Would you like some blame with your no-blame?
The Report is on particularly confused ground when it seeks to blame (!) a supposed “no-blame culture” in the NHS. It claims “throughout the time when the description ‘no blame’ was attached to NHS culture, there was, and still is, a lot of blame within the NHS. That is why it was necessary to introduce whistleblowing protections for those who spoke up about errors and failures within the NHS, and why in 2016 the concept of Speak Out Safely was introduced and, more recently, Freedom to Speak Up. These two steps demonstrate that (a) errors are not always reported or acted upon – because of a fear of blame; and (b) blame is placed on the reporter when they point out errors.”
So there evidently wasn’t a “no-blame” NHS culture, as the frequently-heard threat “I’ll Datix you!” shows.
I also observe that, having talked to quite a lot of senior NHS leaders over the past 26 years, I have not heard any of them describe a need for a “no-blame” culture or standard. Indeed, UHB’s then-chief executive Dame Julie Moore told me in the 2016 Allocate Software-sponsored HSJ piece ‘The Case For Patient Safety’ that “we prefer the term ‘just accountability’ to ‘no blame’. Because it’s fortunately rare, but sometimes there is blame, and someone has done something seriously wrong – and you’ll stand no chance to develop a safety culture if that person can say: ‘Well, you can’t take action against me because we’ve got a no blame culture’.” She was quite right, both then and now.
To FTSE or not to FTSE: that is the question
Entertainingly, the Report asserts that there is “no difference between being a manager in the NHS and a senior manager or leader of a company, listed on the FTSE 100”. There are many obvious differences: principally that FTSE 100-listed companies’ managers are not responsible for universal provision of high-cost safety-critical services to a population whom they can neither charge nor refuse access. (There is also the matter of the quantum of noughts at the end of the number on the salary.)
The Inquiry correctly notes that failing managers are frequently recycled elsewhere in the system with (at least) the active collusion of NHS England, suggesting that “at present, there are too many managers who do not meet the standard that should be expected of them. The need to improve the quality of people and to retain excellent managers is urgent …
“First, the NHS must be prepared to dismiss senior managers for senior misconduct (after due process). Second, it should follow that such managers would not secure employment as a manager in the NHS again …
“It ought to be understood that if a hospital does not invoke the disciplinary process and dismiss if for serious misconduct then, on the current proposals, there would be no basis for barring the manager.” The Report also notes that COC chief executive of these events’ era Tony Chambers described the process of NHS England’s regional and national process of recycling troubled or failing managers as “the donkey sanctuary”.
Clinical regulation: perhaps a less-than-total triumph
Here is the main problem with the argument about regulating and prosecuting senior NHS managers: this system already exists and works remarkably poorly with clinical professionals.
The very well-funded regulators for doctors and nurses are widely despised and distrusted by their constituencies, and have huge backlogs of cases. It is curious to suggest that what is demonstrably working poorly for doctors and nurses is what we should do for managers.
In the case of the NMC, there also seems to have been a refuge for incompetence under Jackie Smith’s leadership, and many readers know that there was a toxic atmosphere towards replacement leader Andrea Sutcliffe. The subsequent NMC interim leader Dawn Broderick was forced to resign on her first day, due to charges of racism. A 2024 independent report found “shocking bullying, racism and incompetence in the organisation responsible for ensuring NHS nurses and midwives in the UK are safe to have around patients”.
Nor is this recent: read Jim Devine MP’s Commons speech on the dysfunctional NMC from 2008.
Medical and healthcare regulation is clearly fairly hard, but it’s probably not that hard. Other countries do not, to my knowledge, display the routine incompetence and dysfunction that seem to be features of UK healthcare regulation, rather than bugs. Learning from what works well elsewhere would be helpful, but we need to be honest about the fact that the NHS and the health system overall has not been what anyone could call a learning-prone organisation for well over a decade.
Here are a few fundamental truths: the really dreadful organisations in the NHS are more or less exactly where they have always been. Factors of population health, geography and reputation are significant deterrents to improvement in these places, particularly where there is a better employment alternative up the road.
It’s possible for clinical leaders to have a comfortable and fairly easy life in these organisations: becoming big fish in small ponds early in their careers, who can chew up and spit out ambitious but badly-advised first-job chief executives sent in on a kamikaze, sorry, turnaround mission.
Here are another few fundamental truths: successfully running an NHS organisation is very hard work; improving a poorly-performing one is even harder, slow and tough and unglamorous work; and not everybody can do it.
And this is best shown by how fast these organisations can unravel. Morecambe Bay was turned around, until it wasn’t again. Long-successful organisations can go downhill precipitously fast: look at what happened to University Hospitals Birmingham after Dame Julie Moore’s departure. UHB was not helped by their leant-on takeover of long-troubled Heart of England FT (which had taken over long-troubled Good Hope). Salford Royal has been in the doldrums since forming the Northern Care Alliance. I could go on, and you will be filling in your own names here.
If you look at these problems and this context and you conclude that regulating managers is the main solution, then my conclusion is that your analysis is bad.
A better report than this would have focused on dysfunctions of organisational culture in the local and national NHS, as the 2022 Messenger Review successfully did. It would have looked at psychological safety, and so at Michael West and colleagues’ classic work on compassionate leadership and effective teams providing better and safer healthcare.
It would have more comprehensively outed the fact that the NHS is consistently bad at systematising learning - whether from the tragic mistakes that lead to public inquiries, or more importantly from the real root causes of good, bad and indifferent performance.
As ‘Cut’ readers know, I’ve been writing about this a lot in recent years (and depressingly, I suspect I will be doing so for years to come): the national NHS leadership evidently does not give one single, solitary fuck about facilitating and supporting improvement: nor has it done so for many years now.
The national NHS leadership’s expressed preference has been to issue a press release solemnly promising that ‘lessons will be learned so this can never happen again’: their revealed preference has been to ignore the issues as swiftly as possible, possibly flinging out a few tokenistic compliance checklists (because of course they always work).
The last genuine effort to systematise learning nationally that actually delivered was the NHS Modernisation Agency, which was stupidly abolished in 2006. If ‘Getting It Right First Time’ were going to do what it says on the tin, then the NHS would be getting it right first time a lot more by now, surely? And I have done the ironically-named ‘NHS IMPACT’ so many times already.
Unless and until the national system leadership starts to take NHS improvement and learning seriously, with the right incentives and support (of which there is no sign), arguing about whether and how to regulate senior managers to improve things is as much theology as discussing how many angels can dance on the head of a pin - albeit rather less interesting.
I’m sending this now as it’s quite late enough: there are a few other important things from this past week, which I’ll do tomorrow morning.
Recommended and required reading
Tomorrow, innit.