Lucy Letby: the worst failure of whistleblower protection we have ever seen in the NHS?

The findings of the independent inquiry are welcome (Sample, 2025), but they usher in a new set of questions. Narratives around whistleblowing failure in this case have revolved almost entirely around the heroic doctors who blew the whistle on Lucy (Protect, 2025: 16-17), while the voices pointing out that she was herself a whistleblower have been much harder to hear.

To date during my career, I have blown the whistle at least three times across three different hospitals, and in every case the response has been retaliative, severe, and shockingly out of proportion to the scale and nature of the problem I was trying to highlight. In one case at least, my experience has been of an escalating retaliatory response in relation to concerns that were originally relatively minor, and if this is also what happened at the Countess of Chester then the conviction of Lucy Letby may represent not only a gross miscarriage of justice, but also the worst failure of whistleblower protection we have ever seen in the NHS.

In December 2024, I wrote to the Royal College of Paediatrics and Child Health (RCPCH), asking them to clarify when and how Lucy Letby may have ever raised, or attempted to raise, concerns about any aspect of the clinical care being provided to babies at the Countess of Chester Hospital, and what action was taken as a result. I was told that they did not know. The RCPCH carried out an invited review at the neonatal unit at the Countess of Chester in September 2016, and as part of that review Lucy was interviewed. However, the RCPCH did not volunteer any information about the content of that interview.

In my own case, the failure of leaders to clearly identify and address the originating concerns was a feature of situations in which the purpose of the retaliatory response was threefold: firstly, to create a smokescreen between potential investigators and those concerns, secondly, to make the case that I was an unreliable witness, and thirdly, to threaten me into silence.

C. Fred Alford is Professor of Government at the University of Maryland, College Park, and the author of Whistleblowers: Broken Lives and Organizational Power (Alford, 2002). He reports on ‘what the scapegoat knows’ (ibid: 3). The scapegoat in the Holy Bible was loaded by the priest with the sins of the Israelites and sent into the wilderness (ibid: 4, citing Leviticus 16: 21-22). The scapegoat was sacrificed for the benefit of the people and in the same way, according to Alford, whistleblowers are sent into the desert of exile, having been afflicted with the sins of the tribe (ibid: 4-5).

Much has been made of the small green post-it note on which Lucy supposedly scribbled her ‘confession’. One of the practices both writers and therapists like very much is known as ‘stream-of-consciousness’ writing. This includes writing continuously without stopping for a set period of time, and writing every thought that enters your mind immediately and exactly as it enters it. This can result in a very fractured piece of prose, unfinished sentences, random words, quotes and reported speech (without quote marks), flights of fantasy, the mixing and blurring of fact and fiction, and all manner of other disruptions and disturbances that would make a literal interpretation by a third party very difficult. All you need to do is insert imaginary quote marks, or the words ‘they are saying that’ before certain phrases, and the meaning of those phrases changes dramatically. The green post-it note was not written before Lucy became aware of her charges. It was written later and in response to the instructions of her counsellor, and as such is entirely meaningless, and that is even before we begin to consider the propensity for the subject under duress to confess to crimes they did not commit, or for the psychologically abused and acutely traumatised subject to begin to fantasise about, or even actually believe they committed, the crime they are being falsely accused of. 

The biggest problem we have with the Letby case, and it’s quite plausible to think that the same psychological dilemma presented itself to Lucy herself, is our basic human need to feel that the world is a safe and just place. In order to live in the world, we need to believe that other people are basically good, kind, fair and honest, that they have our best interests at heart, and that justice will prevail. Sexual health psychologist Zoe Lodrick (n.d.) has written about this in relation to survivors of sexual abuse, who in order to go on living must necessarily reinstate their delusions. In order to feel safe enough to function, which is to say in order to believe that another instance of random violence will not happen to them again in the future, they must believe the original act was their fault. They rationalise this by telling themselves they wore too short a skirt, because the alternative is to believe the world is a terrifying place full of aggressors.

In order to proclaim Lucy’s innocence, we have to be able to believe that an entire system and all the people in it have lied, or if not lied, then at least turned a blind eye to the lies of others: a phenomenon (when it occurs in the workplace) known as ‘organisational bystanding’ (Linstead, 2013). We have to be willing to believe that the very people who are charged with protecting the most vulnerable members of our society – the neonatal doctors and hospital managers – might be not only incompetent, but also sufficiently malicious in intent as to be willing to send an innocent young woman to prison in order to save their own skins, and psychologically we can’t believe that because we need to believe that doctors and hospitals will keep us and our children safe.

This belief is a psychological delusion. The problems in the NHS are endemic and everywhere.

Professor Stephen Linstead reports that organisational bystanding is ‘a necessary condition’ for successful and sustained ‘corruption or moral harassment’ (Linstead, 2013, citing Paull et al., 2012). For me, one of the hardest things the whistleblower knows is that in your time of crisis, everyone will desert you. In one of my cases, it was not the inciting incident that left the worst scars: it was the fact that so many people were involved – colleagues I worked with every day – and not one of them came forward and said I was right when it was obvious to everybody that I was right.

If enough people in metaphorical white coats (by which I mean people in positions of socially-applauded power) told Lucy that she killed those babies, it is quite plausible that she might have started to actually believe that she did, in exactly the same way as the rape victim genuinely comes to believe that she was to blame. The alternative, which is to believe that all those people are deliberately lying and sacrificing her in order to keep their own jobs, is far worse.

The problem is, however incompetent the NHS may be, overall, we need it. In the past, all premature babies below a certain gestation would have died. If we save more than we fail to save then we are doing a good, if imperfect, job. More babies would die if there was no neonatal service at all. Paediatrics as a profession is plagued by staffing issues, and rota gaps are everywhere, but however challenging that situation may be, the show must go on. We simply can’t sack all of the variably incompetent doctors because then there would be no-one left, and no service at all, and that would be much worse.

It may be instructive then to ask whether we as a society have sacrificed Lucy at the altar of continuing care? As horrific as it sounds, the idea of a single rogue psychopath is far less psychologically terrifying for most of us than the reality of a corrupt and broken healthcare system. The rogue psychopath is something we can do something about.

It may be instructive to pause for a moment to consider the sociological question of what kind of social ‘work’ Lucy’s conviction may be doing? It would surely be controversial to suggest that as a society we need these periodic convictions, in order to shore up our healthcare system and broader system of government with a combination of fear and need. We simultaneously fear the random criminal and need the benevolent presence of doctors and hospitals (provided by the state). That is to say, the state needs us to believe that people are bad and the state is good, and not the opposite. By this account, Lucy is likely to remain the sacrificial lamb. To acquit her would send out a very unpopular message indeed.

I read Alford’s book in an effort to understand my own experiences of whistleblowing, and it made sobering reading. As with rape victims, whistleblowers are by definition people who have had their delusions shattered and who struggle to reinstate them in the face of overwhelming evidence that suggests that the modern organisation is a self-serving entity that will not protect those who do not play by its rules. How else can we make sense of the apparently bizarre situation in which an entire team of neonatal consultants became absolutely convinced that Lucy was a murderer, if in fact she was not?

The point I am trying to make is that if the idea that Lucy is innocent is in some way incomprehensibly worse than the idea that she is guilty, then of course the jury would have found her guilty. To find her innocent would be to find the whole team of neonatal consultants and their managers guilty of incompetence, collusion, and conspiracy to put an innocent young woman in jail for life in order to cover their own tracks, and even though they are not in the dock (yet), these questions need to be answered.

They need to be answered because it is the morally and ethically right thing to do to free Lucy if she is innocent, but they also need to be answered because we need to be able to trust and have faith in both our judicial and our healthcare systems. We need to have confidence that they are fit for purpose and that they will come to our aid when we need them in a competent manner.

In addition to our more general need to be, not protected from serial killers but provided with fit-for-purpose services, healthcare professionals also need to be able to have confidence that we will be supported and listened to if we blow the whistle, because the ability to blow the whistle in a safe and effective manner is a key component in developing and maintaining fit-for-purpose services. ‘Justice for Lucy’ then, is not merely a question of seeing justice done for one young woman whose life has been totally destroyed. It is a much bigger issue that we all need to be concerned with, because people who are terrified of retaliation if they blow the whistle either don’t blow it, or they don’t choose to work in failing, crumbling, inadequate services, and then those services get worse and worse until they no longer exist at all.

References

ALFORD, C., F., 2002. Whistleblowers: Broken Lives and Organisational Power. Cornell University Press.

LINSTEAD, S., A., 2013. Organizational Bystanding: Whistleblowing, Watching the Work Go By, or Aiding and Abetting? Management. 16 (5), pp. 680-696.

LODRICK, Z., n.d.. Guilt Article [online]. Available from: https://www.zoelodrick.co.uk/guilt-article (Accessed 28th November 2024).

PROTECT, 2025. The Cost of Whistleblowing: Assessing the cost of whistleblowing failures to the public purse [online]. Available from: https://public-concern-at-work.s3.eu-west-1.amazonaws.com/wp-content/uploads/images/2025/01/30100543/PROTECT_Costs-of-Whistleblowing-ONLINE.pdf (Accessed 9th February 2025).

SAMPLE, I., 2025. Lucy Letby murder convictions: what did the expert panel find? [online]. Available from: https://www.theguardian.com/uk-news/2025/feb/04/lucy-letby-convictions-what-did-the-expert-panel-find (Accessed 9th February 2025).