Professor Joe McDonald, our Principal Associate for health system collaboration, explains how the recent trial of Lucy Letby triggered both personal and professional rage – and the desire to do more to keep patients safe across the NHS.



This is Alba, my only granddaughter. She was born during the trial of nurse and serial killer Lucy Letby. As a psychiatrist, I can normally rationalise about serial killers; speculate on the causes, how a personality can be created that takes pleasure in the pain of other people, perhaps reflect on the horrors of the killer’s own childhood or the genetic influences that left them capable of murdering innocent babies. However, as Alba’s grandfather, all logic is bypassed by this case. Something in my hindbrain is triggered and all I can feel is rage. I cannot begin to imagine the hell Letby has left her victims’ families in. The fact that Letby was under suspicion for so long and allowed to go on killing only adds to my primal grandfatherly rage. I admit it, I’m triggered.

Professionally, I’m also triggered. How come, in the age of computers, can such an obvious outlier go unspotted – well, spotted – but ignored? What have I been wasting the last 30 years of my life on digitisation and patient safety for if this can be allowed to happen?

I was enraged further as events have seen Letby drop out of the news. I see people shrugging their shoulders and saying “well, what can you do?” and filing the case under “shit happens”. My inner grandad says “no”. Enough is enough.

Organisation with a Memory

I drifted into digital health from a background in patient safety and, as an NHS trust medical director, I chaired over a hundred Serious Untoward Incident (SUI) reviews. We diligently investigated and reported on our SUIs, made recommendations and sent our carefully crafted, narrative reports up the line. Maybe somebody read them, maybe not. It was disappointing to see nothing come back down the line and so many similar incidents repeated over the years, while the NHS went through various iterations of approaches to patient safety.

Back when I was a medical director, the framework was Organisation with a Memory (OWMA), the brainchild of Sir Liam Donaldson, arising out of the Bristol Heart Surgery Scandal with the express purpose of making sure the 170 needless deaths of babies in Bristol was never to happen again. A light was shone upon neonatal cardiac surgery outcomes right down to the level of individual surgeons. Neonatal cardiac surgery death rates halved in short order. Was it uncomfortable? Undoubtedly. Was it effective? Undoubtedly. Did it change how the NHS works? Perhaps, for a while. Some cultural lessons were learned and some improvements in individual accountability brought results.

Business as usual or a different legacy?

Unfortunately, the scandals just kept coming, seemingly the organisation does not have a memory or at least it has a memory that is deleted with every generation as it retires.

I was reminded recently by my friend and colleague at Ethical, Andy Kinnear, of the importance of leaving a legacy and, consequently, as someone who is coming to the end of my 40 years in the NHS (much of it in digital and patient safety), I feel I cannot leave matters as they are; where digital and patient safety remain separate silos and the next Letby is free to bring misery to another generation.

We need to change what we normally do. We need to step out of the normal developmental cycle of the NHS patient safety scandal, which generally unfolds in the following phases:

  •  Phase 1: Denial – “I’m a good person and the organisation I lead is full of well-intentioned people just like me. It cannot be that we are delivering bad services.“
  • Phase 2: The bodies pile up – “This is just a run of bad luck, things will pick up.”
  • Phase 3: The whistle is blown – “The usual suspects are agitating, just a few bad apples.”
  • Phase 4: No longer deniable – better get in an independent view – We are starting to take reputational damage, better do something.”
  • Phase 5: Repeat phase 4 until you get a favourable report – “Maybe that report is wrong?”
  • Phase 6: Trust is forced into actual independent scrutiny – “Oh God, we’ve been stuck in phase 1 for months/years.”
  • Phase 7: The truth is out there – “Do I resign or cling on.?”
  • Phase 8: The public inquiry
  • Phase 9: Recommendations
  • Phase 10: Back to business as usual

The lessons are clear; seemingly briefly learnt and yet remarkably similar problems continue to reoccur after just a few years. Allitt, Shipman, Mid-Staffs, Morecambe Bay, multiple reports, Francis, Berwick, Cumberledge, Ockenden etc. A comprehensive list here courtesy of Warwick University.

So, nothing ever changes? We are doomed to repeat the scandal-enquiry-recommendation-business as usual-scandal cycle? No, but we will need to do something we have always shied away from: connect the siloed incident data to appraisal data. Link outcomes and SUIs to locations, teams and, yes, individuals.

This is going to be uncomfortable

The response to Shipman gave us compulsory appraisal and revalidation for medics (a good thing*), which means on an annual basis all medics have to sit down with their appraiser and demonstrate that they are keeping up to date and coming up with a personal development plan which includes reflecting on their SUIs and the collection of multisource feedback. Now, I hear people say, this would not have caught Shipman out, but I believe it might well have given him pause for thought and at least made life harder for the serial killer. What would have stopped him would have been his mortality and SUI stats automatically fed into his appraisal.

Yes. Outcome and SUI data into appraisal systems. I told you it would be uncomfortable.

The other issue is, of course, the singling out of medics for appraisal and revalidation was always a cop-out. Were we really meant to believe only doctors could be bad apples? Appraisal and revalidation and multi-source feedback should be for everyone with access to patients. Everyone.

The opportunity- Smart patient safety incident response framework?

Now, just as the Letby inquiry grinds into motion, NHS patient safety is going through its latest iteration and every trust up and down the country is busy holding many meetings about the latest reinvention of OWAM, now with a new acronym: PSIRF (Patient Safety Incident Response Framework).

Don’t get me wrong, PSIRF has much to recommend it, especially the involvement of patients and families in incident reporting. However, I believe it is an opportunity missed. The output of incidents will be a templated 15-page narrative Patient Safety Incident report.

It is currently a ‘dumb’ form, that with a few digital tweaks (let’s call it smart PSIRF?) could automatically forward itself to an appraisal system which could inform an appraiser of a sudden glut of incident forms in an individual’s appraisal folder or flag up a team with a lot of SUIs. I have discussed this idea with a number of colleagues, and it gets a very mixed response. Medics absolutely get the need for “appraisal and multisource feedback for all” if only on the basis of fairness. “I need to get feedback from multidisciplinary colleagues for my appraisal but I don’t get to reciprocate, so I have to mind my Ps and Qs. It’s culturally divisive and it’s not fair.” On the other hand, many feel under enough scrutiny already without their SUIs automatically coming up at appraisal and are clearly uncomfortable about a feeling of Big Brother watching them. To be honest, I think professionalism is underpinned by the acknowledgement of scrutiny and personal accountability.

Besides, the grandad in my hindbrain wants Letby to feel Big Brother looking over her shoulder, but not just at the Countess of Chester but at Mid-Staffs, Bristol, everywhere.

We have the tech, do we have the will?

 Don Berwick said in relation to his report after the Mid-Staffs scandal: “we need to invest in the constant improvement of staff and systems and that means systemic, well-organised appraisal for all”. Well for me, “systemic and well-organised” means connecting the serious incident reporting data silo to the data in the appraisal systems silos, otherwise we may as well dismiss both industries as meaningless paperchases and let the NHS reinvest the cash in something else.

The equation is: smart PSIRF + appraisal for all = patient safety.

The question is: do we really want patient safety or the cosy status quo? Back in the days of OWAM, we were urged to look to the airline industry for examples of good practice as every pilot’s logbook follows them through their career. In healthcare, we already have the technology to make every healthcare worker’s logbook follow them, but do we have the will? Not thus far.


Professor Joe McDonald,


Principal Consultant, Ethical Healthcare





*Declaration of interest. As well as my work for Ethical I am also part-time Medical Director at SARD JV Limited which provides workforce software including an appraisal and revalidation system.