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.
>> I'm hearing - 'dentists aren't striking because they are simply walking away'. There are dire predictions of the wholesale collapse of NHS dentistry.
