As the country reels from coverage of the conviction of Lucy Letby, a nurse now known to be the UK's most prolific killer of children, many, not least those working in the NHS have asked a simple question: how did this happen?
Despite enormous speculation, no one has discerned any concrete motive as to why Ms Letby, in the words of the sentencing judge, acted ‘in gross breach of the trust that all citizens place in those who work in the medical and caring professions.’
However, there is one grimly familiar detail the case has in common with other tragedies such as the Mid-Staffs scandal: disregard for whistleblowers.
Dr Stephen Brearey was the lead clinician in the hospital's neonatal unit, who first raised concerns about Ms Letby. Since her conviction, he has said that his concerns were continually ignored by managers.
When the organisation visited the Countess of Chester Hospital, the CQC commented that their discussions with the trust's medical director included the reports by staff of alleged challenges in raising concerns with managers but denied that the high mortality rate had been highlighted to them during the visit.
For those who remember the Mid-Staffs scandal, this will be familiar reading. Nurses who raised the alarm in that case say they were threatened, harassed, with one saying she was too scared to leave her home. Yet ten years on, there still does not exist a rigorous framework to assist those who wish to report concerns.
Raising and escalating concerns is a central clause in the Nursing and Midwifery Council (NMC) Code, which says nurses must act without delay if you believe that there is a risk to patient safety or public protection.
In the aftermath of Mid-Staffs, the Francis public inquiry report stressed the importance of transforming culture and attitudes, developing robust safeguarding strategies and implementing effective complaint handling and recording systems. The report also called for an end to the gagging clauses that limit public disclosures, and instead to foster a culture of openness, transparency and legally binding duty of candour. The Department of Health subsequently commissioned Donald Berwick to lead a review and report on making zero harm a reality within the NHS.
Despite this, a decade later we are now seeing another tragedy that might have been prevented if clinicians had been supported in raising their concerns.
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