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Countess of Chester Hospital Inquiry
04 September 2023
Lead MP
Steve Barclay
Debate Type
Ministerial Statement
Tags
NHSEmployment
Other Contributors: 28
At a Glance
Steve Barclay raised concerns about countess of chester hospital inquiry in the House of Commons. A government minister responded. Other MPs also contributed.
How the Debate Unfolded
MPs spoke in turn to share their views and ask questions. Here's what each person said:
Government Statement
On August 18, Lucy Letby was convicted for the murder of seven babies and attempted murder of six others at the Countess of Chester Hospital. The minister announced an independent statutory inquiry led by Lady Justice Thirlwall to examine broader circumstances including the trust's response to clinicians' alarms, NHS conduct, and regulatory actions. Families will shape the terms of reference. Actions taken include appointing a national director for patient safety in 2018, launching medical examiner programmes, freedom-to-speak-up guardians, fit-and-proper-person tests for board members, and maternity safety measures. The minister committed to statutory medical examiners, reviewing Kark's recommendation on senior managers, strengthening speaking up policies, monitoring neonatal services, and exploring Martha’s rule for patient safety.
Question
Can you provide an update on the Essex statutory inquiry and its current status?
Minister reply
The Minister announced Baroness Kate Lampard as the chair for the statutory inquiry into NHS mental health in-patient facilities across Essex. Further updates will be provided based on input from members of the House and impacted families.
Wes Streeting
Lab
Ilford North
Question
What measures are being taken to prevent future similar tragedies by ensuring consistent standards for management in NHS?
Minister reply
The Minister has committed to reviewing Kark's recommendation 5 regarding the disbarment of senior managers with a record of poor performance or misconduct. The Government will also consider bringing in a regulatory system for NHS management, alongside standards and quality training.
Wes Streeting
Lab
Ilford North
Question
The MP expressed strong support for the inquiry and praised whistleblowers who exposed Letby's crimes. He questioned why senior leaders at Countess of Chester Hospital were still employed despite clear issues, and called for better regulation of NHS managers to prevent future tragedies.
Minister reply
The minister acknowledged the importance of family involvement and stated that measures have been taken to address accountability but more work needs to be done. The Government will reconsider recommendation 5 from the Kark review in light of new evidence.
Question
Expressed sympathy for victims' families and welcomed the judge-led statutory inquiry. Emphasised the need for a one-team approach between managers and clinicians to prevent defensive medicine.
Minister reply
Agreed with the need for a collaborative approach and expressed interest in encouraging more clinicians into management roles while ensuring accountability within the NHS.
Samantha Dixon
Lab
Chester North and Neston
Question
Terrible crimes have been committed in the Countess of Chester Hospital in my constituency. I thank the Secretary of State for meeting and listening to the families at the heart of this tragic case and for instituting a statutory inquiry into the circumstances surrounding these crimes. Given that the scope of Cheshire police’s Operation Hummingbird has now broadened, what reassurance can the Secretary of State offer my community about our hospital?
Minister reply
First of all, I pay tribute to the hon. Lady for the work she has done with the families and the staff in response to these terrible events. It is important that we reassure patients who are using the Countess of Chester Hospital now about the measures that have been put in place; that is why I wanted to bring to the House’s attention House the steps that have already been taken.
Question
I commend the Secretary of State on his decision to upgrade the inquiry and put it on a statutory footing, something I know many of the families wanted. What steps is he taking to ensure consistency right across the NHS estate?
Minister reply
My hon. Friend raises an extremely important point. That is why in 2022 the guidance around the national freedom to speak up policy was strengthened—I mentioned the appointment in September 2022 of Henrietta Hughes as the Patient Safety Commissioner—and why significant work has been done on the quality of data, looking at the work for example of the getting it right first time teams, so that the data can be analysed more effectively to alert investigation.
Justin Madders
Lab
Ellesmere Port and Bromborough
Question
There is no doubting the impact this case has had on the whole community. However, as a constituency MP, when I was briefed by the management at the time the issues first emerged, I can say a very different picture was painted from the one we see today. There are serious lessons to be learned from what went on with the senior management.
Minister reply
The hon. Gentleman raises an extremely important point. It is right that we focus on that and ensure that the concerns about the revolving door are addressed. On the decision taken by my predecessor, my understanding is that the recommendations accepted from Kark were viewed as effective in addressing that—obviously, the events to which this statement relates have happened since—but I have asked NHS England colleagues in the Department to look again at testing them further in the light of the evidence that has come through from the court case in particular.
Priti Patel
Con
Witham
Question
My heartfelt prayers and thoughts are rightly with the families, whose heartbreak and suffering is just unimaginable. I welcome the tone that the Secretary of State has taken on ensuring that no stone is unturned in the quest for justice. Can he some provide some assurance so that the 80-plus families who did not engage with the inquiry previously come forward, give evidence and have confidence that their evidence will lead to justice for the loved ones they are missing because of what happened at the mental health trust?
Minister reply
I am keen to give my right hon. Friend that assurance. I know that she has personally championed—the interests of families in Essex to ensure that they get the answers they need. Indeed, she very effectively conveyed to me the concerns about the inquiry in Essex hitherto. Our focus—I think this is an area of consensus across the House—has to be on ensuring that families get the answers that they legitimately deserve.
Question
Like other hon. Members across the House, and, in particular, the families of the victims of this horrendous situation, I want to ensure that those managers who have somehow recycled themselves into leadership positions face stronger regulation and accountability.
Minister reply
It will not surprise the hon. Gentleman that a central concern of the families when I met them was the extent to which they felt fobbed off when concerns were raised and the ability of those managers either to continue in post or to move to new posts. It is very much central to some of the safeguards that have been put in place through the recommendations from Kark that have already been accepted.
Question
A major concern for me is that managers ignored consultants who had raised serious issues. Does he support a strengthening of the whistleblowing legislation so that all whistleblowers know that they will be heard and protected?
Minister reply
To provide some reassurance to my hon. Friend, the Public Interest Disclosure Act 1998 was strengthened in 2018. The freedom to speak up guardians have also been implemented since these events, and their role has been strengthened further in the guidance.
Mark Tami
Lab
Alyn and Deeside
Question
It is also vital that any other parents who have concerns about the treatment of their child when Letby was working at Chester and Liverpool have those concerns fully investigated or reinvestigated by the police, so will the Secretary of State ensure that the Home Secretary provides whatever resources the police need to make that happen?
Minister reply
Given the gravity—the seriousness—of the cases before the House, this issue is something that all Ministers are very seized of, but I will of course relay the right hon. Gentleman’s point to the Home Secretary. From talking to the team, I know that specific funding had been allocated for that in response to the seriousness of these cases.
Vicky Ford
Con
Southport
Question
It is impossible to imagine the depths of grief of families affected by baby deaths and it is right that efforts are made to help them get truth and justice. Will the Secretary of State ensure families will be involved in terms of reference, agreed swiftly, with necessary resources for the inquiry?
Minister reply
The Minister agrees on importance of family involvement and rapid agreement of terms of reference. He underscores his commitment to statutory footing of Essex inquiry highlighting quicker resolution, ensuring availability of court-established factual information.
Tim Farron
Lib Dem
Westmorland and Lonsdale
Question
How does the Secretary of State ensure future whistleblowers will be protected when speaking out to save lives, given past issues with marginalising whistleblowers?
Minister reply
The Minister highlights his long-standing championing of whistleblower protection. He mentions strengthened data transparency and freedom-to-speak-up measures, acknowledging Morecambe Bay maternity services failings.
Robert Buckland
Con
South Swindon
Question
How does the Secretary of State ensure open justice is maintained in full while respecting families' privacy wishes during inquiries?
Minister reply
The Minister agrees on importance of open justice but also underscores respect for family's wishes regarding privacy, especially considering impact on other young children.
Rachael Maskell
Lab Co-op
York Central
Question
What measures will the Secretary of State ensure to provide independent external routes for raising concerns and accountability scrutiny in healthcare services?
Minister reply
The Minister agrees on importance and mentions existing safeguards post-Francis report, including roles like medical examiners. He highlights that inquiry will examine effectiveness.
Caroline Johnson
Con
Sleaford and North Hykeham
Question
What steps does the Secretary of State seek to develop clear lines of accountability, prevent poor managers from evading accountability, and provide pathways for escalation beyond a trust?
Minister reply
The Minister mentions medical examiners working with coroners. He states inquiry will look into roles like those of the medical director, Royal College reports, and board issues around patient safety.
Barbara Keeley
Lab
Worsley and Eccles South
Question
What assurances does the Secretary of State give regarding full exploration of NHS governance and HR processes following allegations about managers accused of ignoring warnings moving to other trusts?
Minister reply
The Minister assures full exploration by Justice Thirlwall's inquiry. He mentions that NHS England is looking at concerns raised, including regulation of managers in re-employment issues.
Andrew Selous
Con
Central Bedfordshire
Question
In reference to a previous case where the speaker was a whistleblower against an orthopaedic surgeon at his local hospital, he inquired about key reforms that will ensure brave clinicians who speak up are heard and prevent incidents of management attempting to cover up issues.
Minister reply
Key reforms include Getting It Right First Time (GIRFT), strengthening freedom to speak up guardians, appointing a new patient safety commissioner, enhancing the Public Interest Disclosure Act, child death overview panels, and medical examiners.
Ben Bradshaw
Lab
Exeter
Question
He inquired why the Secretary of State is waiting for another review or inquiry before closing the revolving door for hospital managers who have been involved in previous scandals.
Minister reply
While accepted Kark recommendations address concerns about the revolving door, discussions are ongoing with NHS England to ensure appropriate support and accountability for managers at difficult trusts.
Shailesh Vara
Con
North West Cambridgeshire
Question
He asked for assurance that families affected by the Lucy Letby case will receive all necessary support during the statutory inquiry and beyond.
Minister reply
The minister emphasised engaging with families at the earliest opportunity to ensure they receive all required support, prioritising their wishes as central to how Justice Thirlwall will structure the inquiry.
Dwyfor Meirionnydd
Question
She inquired about assurance that cross-border patient safety issues would be included within the statutory inquiry’s terms of reference.
Minister reply
The minister acknowledged the importance of cross-jurisdictional cases and confirmed that Judge Thirlwall will consider how to capture such cases affecting babies or families from Wales.
Luke Hall
Con
Wansbeck
Question
He requested assurance that families’ anonymity would be protected during the inquiry if they so desired.
Minister reply
The minister highlighted Justice Thirlwall's sensitivity to family wishes, balancing privacy concerns with the appropriate balance between public and private hearings.
Diana R. Johnson
Lab
Kingston upon Hull North and Cottingham
Question
She questioned why recommendation 5 of the Kark review was not implemented despite addressing senior managers in the NHS.
Minister reply
NHSE colleagues are revisiting that decision without waiting for the inquiry, as concerns about the revolving door have come to light through recent events.
Anna Firth
Con
Havant
Question
She welcomed the announcement of a full, judge-led statutory inquiry and expressed hope for reassurance that this inquiry would hold senior managers accountable.
Minister reply
The appointment of a Court of Appeal judge underscores the seriousness of the inquiry into Letby's murders, while the Essex NHS mental health inquiry has also moved to a statutory footing with Baroness Lampard chairing.
Helen Morgan
LD
North Shropshire
Question
She expressed concern about management failings in the NHS and requested reassurance that this time, when they say “never again,” it will be meaningful.
Minister reply
The minister highlighted significant actions taken following previous reviews, including implementing recommendations on medical examiners, strengthening under PIDA, and using GIRFT to review data.
Alison McGovern
Lab
Birkenhead
Question
Could I come back to the question asked by my hon. Friend the Member for York Central about duty of candour? Ten and a half years ago, I stood here in this House and listened to the now Chancellor talk about duty of candour. How is it that families were not entitled to every bit of information when they asked for it? What review has the Secretary of State already conducted into the effectiveness of duty of candour?
Minister reply
Over 10 years, significant action has been taken to strengthen transparency and data access, along with safeguards. The purpose of the inquiry is to test whether further action is needed. NHS England has been asked to review areas where recommendations have been made and determine what additional actions can be taken.
Jim Shannon
DUP
Strangford
Question
Can the Secretary of State confirm that any procedural changes learned from this case will be shared throughout trust areas? How can Government ensure that finances do not preclude precautions for protecting babies and staff, and will the inquiry’s findings be shared with all devolved Administrations?
Minister reply
I commit to sharing the inquiry findings with all Administrations across Great Britain and Northern Ireland. It is crucial that lessons are learned and applied UK-wide, including data handling and looking at variations across the United Kingdom.
Shadow Comment
Wes Streeting
Shadow Comment
Shadow welcomed the inquiry under Lady Justice Thirlwall and the appointment of Baroness Lampard. He acknowledged staff bravery in whistle-blowing and called for ongoing family involvement in decisions during the inquiry. Labour supports a regulatory system for NHS managers, including disbarment for serious misconduct as recommended by Kark's review. The shadow urged further action to prevent future tragedies.
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