The overwhelming majority of healthcare practitioners go to work to give their best to those receiving their care despite sometimes testing situations due to limited resources or other constraints. However, the Letby criminal case has challenged us to consider that there may be a healthcare practitioner somewhere in the NHS whose motives are malevolent and their whole practice might be based on deception. Beverly Allitt and Harold Shipman were similarly convicted of murdering vulnerable patients under their care.
It is clear that it is not easy to identify and secure convictions of malevolent practitioners because much healthcare practice takes place hidden from view, even within hospital settings. A rise in hospital mortality may be explained away as just a random statistical variation which occurs occasionally with A ‘blip’ of increased mortality in patients. This may be due to a rise in the number of patients who had entered hospitals being particularly sick and succumbing to their conditions despite the best efforts of those involved in their care. Hospital patients receive care from multiple doctors and nurses and so, working out if the deaths are associated with a particular practitioner is hugely challenging. Even then, having identified a possible association between an individual practitioner and a patient death to secure a prosecution, the act of commission has first to be identified, and then proven beyond reasonable doubt in a jury trial to meet the legal benchmark for a criminal conviction.
Healthcare practice in the home is even less visible, with most nursing care and general practice being unobserved unless a carer is present. Indeed, Harold Shipman exploited this lack of observation by others to kill up to 250 of his patients over 30 years (1971–1998), which resulted in a number of changes relating to death and cremation certification (Shipman Inquiry, 2002), the management of controlled drugs in the community (Shipman Inquiry, 2004a), and the handling of complaints and concerns about GPs (Shipman Inquiry, 2004b). For those whose loved ones were murdered by Dr Shipman, the question remains: how did his behaviour go unchallenged for so long? A grandson of one of Dr Shipman's victims, Edwin Flay, an actor and writer, has attempted to share his deeply personal story, including his recollections of the ‘likeable’ Hyde GP and the shock of learning that his grandmother had been killed, in a one-man play ‘The Quality of Mercy’. The play is set in a prison cell before Dr Shipman committed suicide, and is part of this year's Edinburgh Festival Fringe.
‘The Shipman trial and inquiry challenged the deferential culture surrounding doctors and other authority figures; however, healthcare delivery is predicated upon trust between patients and their clinicians, including nurses.’
The Shipman trial and inquiry challenged the deferential culture surrounding doctors and other authority figures; however, healthcare delivery is predicated upon trust between patients and their clinicians, including nurses. Indeed, the Nursing and Midwifery Council (NMC) Code (2015) is clear that the values and principles governing a registrant's practice are neither negotiable nor discretionary. There are four elements to the NMC Code, namely: prioritise people, practise effectively, preserve safety, and promote professionalism and trust. A registrant is required to put ‘the interests of people using or needing nursing first’, which includes acting in the best interests of people at all times and to ‘act without delay’ if it is believed that ‘there is a risk to patient safety or public protection’.
The challenge for healthcare professionals is to combine trust in clinical colleagues to achieve effective multidisciplinary working, while retaining a watchful gaze over colleagues and their practice to protect patients from harm. A feature of Serious Case Reviews of child deaths is professionals in contact with the families adopting a ‘rule of optimism’, which describes professionals viewing their observations, even potentially concerning observations, through an optimistic gaze and always thinking the best of families so that questionable events are attributed ‘reasonable’ explanations despite the contrary evidence. Thus, practitioners working alongside malevolent practitioners may similarly adopt a ‘rule of optimism’, finding it hard to believe that a clinical colleague could intentionally harm a patient, contrary to all professional ethics and social norms.
The challenge of taking action when professional performance falls below par is echoed in the ‘failure to fail’ phenomenon in nursing, that is, giving pass grades to student nurses whose clinical performance is unsatisfactory. The phenomenon has attracted increasing interest over the last 20 years as concern have been raised that new registrants may have ‘slipped through’. Hughes et al's (2016) literature review highlighted how failing a student was a difficult experience, which was an emotional process and demanded confidence on the part of assessors. The NMC (2018) has issued guidance setting out the expectation that practice assessors should not recommend the progression of students whose performance causes concern and, further:
‘Community nurses can do their bit to bolster the public's trust and confidence in the nursing profession by demonstrating their contribution to people's lives and wellbeing as they deliver exemplary care in the home…they should whistle blow and use other means to alert colleagues or their leaders if a fellow professional's behaviour or practice does not appear to be ‘quite’ right.’
‘If there is an immediate concern or risk to the public from the student's performance, the practice assessor must take appropriate action, such as recommending the student for removal or suspension from a placement or course.’
Trust in the professionalism of healthcare professionals is an essential prerequisite for clinical relationships between patients and those delivering clinical care. The promotion of trust features in all the regulatory frameworks governing the different healthcare professions in the UK, including that of the NMC. Unfortunately, the confidence of the general public in nurses will have been undermined by the Letby trial and its outcome, and it is not helped by some nursing colleagues continuing to express their dismay and disbelief at Letby's conviction.
Community nurses can do their bit to bolster the public's trust and confidence in the nursing profession by demonstrating their contribution to people's lives and wellbeing as they deliver exemplary care in the home. More importantly, they should whistle blow and use other means to alert colleagues or their leaders if a fellow professional's behaviour or practice does not appear to be ‘quite’ right. People will always ask ‘how did Dr Shipman's or Letby's behaviour go unchallenged for so long?’.
The Government has announced a judge-led statutory inquiry into the circumstances behind the murders and attempted murders of infants at the County of Chester Hospital citing the need to ‘learn vital lessons’ and to provide answers for the families involved alongside the wider circumstances around what happened at the Trust, including the handling of concerns and governance (UK Government, 2023a; 2023b). An inquiry will take time to deliver its report(s) and in the meantime, it behoves current and future community nurses to play their part in ensuring that healthcare delivery is as safe as possible and that any malevolent practitioners in contact with their clients are identified swiftly and removed from their role as quickly as possible. The reality remains that malevolent practitioners are extremely rare but that is little comfort to their victims or their families, and further, who knows where another malevolent practitioner may be lurking.