Lucy Letby – Reflections and Reaction


Paul WhiteingBy Paul Whiteing, Chief Executive, Action against Medical Accidents

August 2023



Like everyone who has followed the Lucy Letby case and trial with any level of interest, there is a sense of relief that the jury have discharged their duty and made their verdict in this highly complex case. Before we turn to its implications, we first share our thanks to the jury for enduring an extremely difficult trial over an extended period and with so much evidence to consider and analyse. More importantly, we express our deep sympathy to all of the families who have been affected by this case and who not only lost a much-loved baby but then had to endure the horrors of reliving the experience in this way and over several years.

Learning from Tragedy: Preventing Future Occurrences

Many people will now turn to address the important question of how this could have been prevented from happening – if at all – and to learn lessons from this case so that this may never happen again. And that must be right. We should do that at pace but thoroughly, and the Government should commit to implementing necessary changes.

The Rarity of Such Events

But equally, we should caution that events such as these, as tragic as they are, are thankfully rare.

AvMA –now over 40 years old – is dedicated to supporting people who have suffered a medical accident or harm. But nearly all of the cases we see involve issues that emanate from failures which are a combination of people and system errors. Those cases may meet the high bar of medical negligence, but they seldom are wilful, deliberate and malicious acts designed to cause severe harm let alone death. We must keep perspective while addressing the callousness of the crimes committed and find ways to prevent them from happening again without unfairly accusing medical professionals.

AvMA’s Campaign for Patient Safety

AvMA’s long experience supporting harmed patients has helped us argue for safety improvements so issues such as these are detectable sooner. Complaints processes, independent investigations, Coroners inquests, and whistleblowing systems already exist. Could any of these have identified issues earlier? And if not, why not?

Learning from Lived Experiences

And in bringing the experts to the table to consider these lessons from this case, we would strongly urge that included in this are the numerous patients and patient groups who have lived experiences of patient harm. They would make a vital contribution to considering what more can be done to identify patterns of suspicious, poor and/or substandard care at an earlier stage.

And One Last Thought

Finally, insofar as Coroners can make recommendations in reports about the Prevention of Future Deaths, there is an absence of oversight of these reports from the various Coroners. That is why we support the charity Inquest in calling for the establishment of a National Oversight Mechanism to monitor progress against these reports from Coroners to ensure they are effectively implemented. That is something the Government could commit to today.