NHS duty of candour 'not working' - Letby inquiry

Lucy Letby is serving a whole-life term for the baby killings

"Puny fines" for NHS bodies which breach their duty to be candid with patients means there is "no deterrent", the public inquiry into Lucy Letby's crimes has heard.

A former senior ombudsman said it means the statutory obligation to be open and transparent with patients and their families, known as the duty of candour, is "not working in the NHS".

Sir Rob Behrens was the Parliamentary and Health Service Ombudsman from April 2017 to March 2024 and gave evidence to the Thirlwall Inquiry, which is examining Letby's baby killings at Countess of Chester Hospital.

He said: "It doesn't work because it doesn't apply to individuals, it applies to persons and that is interpreted as a public body."

He continued: "Secondly, the fines issued are so puny that it doesn't have impact on the behaviour of the leaders of the (NHS) trust.

"Time and time again, we have seen senior managers and boards are more interested in preserving the reputation of their organisation rather than dealing with patient safety issues."

Sir Rob said current whistleblowing laws in England were also not working, with doctors fearing the end of their careers if they speak out.

Sir Rob Behrens said that whistleblowers feared speaking out in the NHS

He said Freedom to Speak Up Guardians - designated members of staff there to support people in raising concerns within the NHS - did a "brilliant job" but some had told him they themselves did not feel able to be frank and open about their own experiences for fear they too would be disciplined.

Sir Rob said some NHS trust leaders had accused investigators or whistleblowers of "undermining" them.

"You have to acknowledge where things go wrong", he said.

"One of the great things that I have learnt as ombudsman is the heroic behaviour of parents and family members in seeking to keep cases going which otherwise would have fallen by the wayside, and that should not be the case."

No complaints regarding patient care at the Countess of Chester's neonatal unit were made to the ombudsman in 2015 and 2016 when Letby attacked infants in her care, the inquiry heard.

The Thirlwall Inquiry has heard that consultants like Dr Stephen Brearey (pictured) were threatened with disciplinary action after raising concerns

Consultant paediatricians voiced fears to hospital bosses that the nurse was deliberately harming babies following the deaths of two triplet boys in June 2016 but police were not called in until May 2017.

Former chief executive Tony Chambers has denied that he sought to "ruin the careers" of medics Dr Ravi Jayaram and Dr Stephen Brearey after they brought the concerns to his attention.

Letby, 34, from Hereford, is serving 15 whole-life orders after she was convicted at Manchester Crown Court of murdering seven infants and attempting to murder seven others, with two attempts on one of her victims, between June 2015 and June 2016.

The inquiry, sitting at Liverpool Town Hall, will hear evidence until January, with findings expected to be published in autumn 2025

Additional reporting by the Press Association