Wes Streeting – 2023 Speech on the Countess of Chester Hospital Inquiry

The speech made by Wes Streeting, the Shadow Secretary of State for Health and Social Care, in the House of Commons on 4 September 2023.

I strongly echo the sentiments of the Secretary of State and thank him for advance sight of his statement. I welcome the appointment of Lady Justice Thirlwall to lead the inquiry into the crimes committed by Lucy Letby, and I strongly welcome his appointment today of Baroness Lampard to lead the statutory review in Essex. I look forward to receiving further updates from the Secretary of State as soon as possible.

Turning to the case of Lucy Letby, there are simply no words to describe the evil of the crimes that she committed. They are impossible to fathom. Although she has now been convicted and sentenced to a whole-life order, the truth is that no punishment could possibly fit the severity of the crimes she committed. With Cheshire police’s investigation having expanded to cover her entire clinical career, we may not yet know the extent of her crimes. What we do know is that her victims should be starting a new school term today. Our thoughts are with the families who have suffered the worst of traumas, whose pain and suffering we could not possibly imagine, and who will never forget the children cruelly taken from them. We hope that the sentencing helped to bring them some closure, even though the cowardly killer dared not face them in court.

I wish to pay tribute to the heroes of this story: the doctors who fought to sound the alarm in the face of hard-headed, stubborn refusal. This murderer should have been stopped months before she was finally suspended. Were it not for the persistent courage of the staff who finally forced the hospital to call in Cheshire police, more babies would have been put at risk. I am sure the whole House will want to join me in recognising Dr Stephen Brearey and Dr Ravi Jayaram, whose bravery has almost certainly saved lives.

Blowing the whistle on wrongdoing is never easy, which is why it should not be taken lightly. Indeed, we can judge the health of an institution by the way that it treats its whistleblowers. The refusal to listen, to approach the unexplained deaths of infants with an open mind and to properly investigate the matter when the evidence appeared to be so clear is simply unforgivable. The insult of ordering concerned medics to write letters of apology to this serial killer demonstrates the total lack of seriousness with which their allegations were treated.

I welcome the fact that the Secretary of State has changed the terms of the inquiry and put it on a statutory footing. There must be no hiding place for those responsible for such serious shortcomings. It is welcome that the inquiry will have the full force of the law behind it, as it seeks to paint the full picture of what went wrong at the Countess of Chester Hospital, and it is right that the wishes of the families affected have been listened to. I welcome the fact that they will be involved in the drawing up of the terms of reference.

I ask the Secretary of State, people right across Government and people who hope to be in government to make sure that, in future, in awful cases such as this, families and victims are consulted at the outset. Can he assure the House that the families will continue to be involved in decisions as the inquiry undertakes its work?

Mr Speaker, no stone can be left unturned in the search for the lessons that must be learned, but it is already clear that there were deep issues with the culture and leadership at the Countess of Chester Hospital. This is not the first time that whistleblowers working in the NHS have been ignored, when listening to their warnings could have saved lives. Despite several reviews, there is no one who thinks that the system of accountability, of professional standards and of regulation of NHS managers and leaders is good enough.

Why were senior leaders at the Countess of Chester Hospital still employed in senior positions in the NHS right up to the point that Lucy Letby was found guilty of murder? The absence of serious regulation means that a revolving door of individuals with a record of poor performance or misconduct can continue to work in the health service. Does the Secretary of State agree that that is simply unacceptable in a public service that takes people’s lives into its hands?

The lack of consistent standards is also hampering efforts to improve the quality of management. I am sure the Secretary of State will agree that good management is absolutely vital for staff wellbeing, clinical outcomes, efficient services and, most of all, patient safety. The case for change has been made previously. Sir Robert Francis, who led the inquiry into the deaths at Mid Staffs, argued in 2017 that NHS managers should be subject to professional regulation. In 2019, the Kark review, commissioned by the Secretary of State, called for a regulator to maintain a register of NHS executives, with

“the power to disbar managers for serious misconduct”.

In 2022, the Messenger review commissioned by the right hon. Member for Bromsgrove (Sajid Javid) recommended a single set of core leadership and management standards for managers, with training and development provided to help them meet these standards. We must act to prevent further tragedies, so I welcome the Secretary of State’s announcement that his Department is reconsidering Kark’s recommendation 5. Labour is calling for the disbarring of senior managers found guilty of serious misconduct, so I can guarantee him our support if he brings that proposal forward.

The Secretary of State should go further. Will he now begin the process of bringing in a regulatory system for NHS management, alongside standards and quality training? Surely we owe it to the families and the staff who were let down by a leadership team at the Countess of Chester Hospital that was simply not fit for purpose.

Finally, I know that I speak for the whole House when I say that the parents of Child A, Child C, Child D, Child E, Child G, Child I, Child O and Child P are constantly in our thoughts, as are the many other families who worry whether their children have also been victims of Lucy Letby. We owe it to them to do what we can to prevent anything like this from ever happening again. As the Government seek to do that, they will have our full support.

Steve Barclay

I thank the hon. Gentleman for the content of his response and the manner in which he delivered it. I think it underscores the unity of this House in our condemnation of these crimes, and our focus on putting the families at the centre of getting answers to the questions that arise from this case. I join him in paying tribute to those consultants who spoke up to trigger the police investigation and to prevent further harm to babies. I note the further work that the police are doing in this case, and also pay tribute to the police team, which I had the privilege of meeting. They have worked incredibly hard in very difficult circumstances in the course of this investigation.

As the hon. Gentleman said, the families are absolutely central to the approach that we are taking. That is why I felt that it was very important to discuss with them the relative merits of different types of inquiry, but their response was very clear in terms of their preference for a statutory inquiry. I have certainly surfaced to Lady Justice Thirlwall some of the comments from the families in terms of the potential to phase it. Of course, those will be issues for the judge to determine.

On the hon. Gentleman’s concerns around the revolving door, clearly a number of measures have already been taken, but I share his desire to ensure that there is accountability for decisions. As Members will know, I have been vocal about that in previous roles, and it is central to many of the families’ questions on wider regulation within the NHS.

The hon. Gentleman mentioned the importance of good management. I am extremely interested in how, through this review and the steps we can take ahead of it, we give further support to managers within the NHS and to non-exec directors. The Government accepted in full the seven recommendations of the Messenger review. The Kark review was largely accepted. There was the issue of recommendation 5, which is why it is right that we look again at that in the light of the further evidence.

It is clear that a significant amount of work has already gone in. A number of figures, including Aidan Fowler and Henrietta Hughes, have focused on safeguarding patient safety, but in the wake of this case we need to look again at where we can go further, which the statutory inquiry will do with the full weight of the law. I am keen, however, that we also consider what further, quicker measures can be taken. Indeed, I have been in regular contact with NHS England to take that work forward.