When the statutory inquiry into nurse Lucy Letby's murder of seven babies and attempted murder of six others reports its findings, it is likely to result in vital lessons not just for Countess of Chester Hospital but also for the wider NHS.
The harm done to patients and the impact this has had on their families and on staff who worked with Letby is devastating. The NHS must take all possible steps to prevent this from happening again.
But what's already clear is one issue that must be examined is culture.
There is a common thread that runs through previous scandals. Ten years ago, the findings of the public inquiry into the failure of care at Mid-Staffordshire NHS Hospital were published. Failure that saw patients die because of poor care and action not being taken quickly enough, despite the warnings of both patients and staff.
Just last year, an investigation into the maternity services at the Shrewsbury and Telford Hospital NHS Trust again highlighted tragic failures to listen to families and learn from clinical incidents.
Although the inquiry into what happened at the Countess of Chester hospital is yet to report, it is likely to highlight a situation where NHS leaders did not listen to staff who sounded the alarm.
So what can be done? Previous scandals have unequivocally shown how failing to listen and act on people's concerns can result in catastrophic consequences. Many have also set in training reforms to improve safety.
The first question is what can be done to improve the mechanisms that are already in place, and how can they be used to best effect. Do staff and patients know where they can go to raise concerns? Do regulators need to do more to ensure issues do not fall through the cracks?
But there also remains an issue of culture, which cannot be addressed by regulation alone. How do we ensure every NHS service recognises that a culture of listening is central to providing safe, high-quality care?
The establishment of integrated care systems allows health and care decision-makers to think about how the culture of services needs to change to become more open. A culture where, from the frontline upwards, the concerns of staff and patients are viewed as an early warning system to highlight safety issues, and organisations are open to acknowledging problems and learning from them.
We need to get to a point where listening to the concerns of staff and patients is seen as integral to improving the quality and safety of care.
With the system under such massive pressure, with record waiting lists and staff shortages, finding space to have this conversation will not be easy. But to prevent future tragedies, we must.
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