A statutory public inquiry is not always the most effective vehicle for learning lessons in the NHS

The statutory public inquiry chaired by Kathryn Thirlwall into the murder and attempted murder of babies by former neonatal nurse Lucy Letby at the Countess of Chester Hospital Foundation Trust follows a well trodden path that has led to many NHS inquiries. As with other examples of wrongdoing or neglect, concerns about care raised by staff are ignored or suppressed and not acted upon by managers. Those raising the alarm are ostracised and have their motives impugned, and eventually—often years later—an inquiry is set up to establish what went wrong. NHS England has made a commitment that “lessons will be learned” from the tragic events at the Countess of Chester Hospital Foundation Trust.1 However, a statutory public inquiry may not always be the most effective and efficient vehicle for investigating problems and drawing lessons that can lead to substantial improvement in care across the NHS.The role and impact of NHS…
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