Jeremy Hunt has said ministers took “too long” to introduce medical examiners to investigate deaths in the NHS, as he apologised to the families of Lucy Letby’s victims.
Giving evidence at the Thirlwall inquiry on Thursday, the former health secretary said he had “ultimate responsibility” for the NHS at the time Letby committed her “appalling crime” of murdering babies at the Countess of Chester hospital in 2015 and 2016.
“It happened on my watch as health secretary and, although you don’t bear direct personal responsibility for everything that happens on every ward in the NHS, you do have ultimate responsibility for the NHS,” he said.
“Insofar as lessons were not learned from previous inquiries that could have been, or the right systems were not in place that could have prevented this appalling tragedy, then I do have ultimate responsibility and I want to put on record my apology to the families for anything that didn’t happen that could potentially have prevented such an appalling crime.”
The inquiry, led by Lady Justice Kathryn Thirlwall, is examining the circumstances surrounding the murder of seven babies and attempted murder of seven others by Letby on the hospital’s neonatal unit.
The former nurse, 35, is serving 15 whole-life prison terms but maintains her innocence. Her legal team is preparing a legal challenge to the Criminal Cases Review Commission.
Hunt, who was health secretary from 2012 to 2018, said his government took “too long” to introduce independent medical examiners to the NHS after they were first proposed in 2004, six years before the Conservatives came to power.
Medical examiners are senior doctors who carry out independent scrutiny of deaths that are not investigated by coroners. They were introduced widely last September, 20 years after they were first proposed as a result of the Harold Shipman inquiry in 2004, then again by the Francis inquiry into the Mid-Staffordshire scandal in 2013.
The proposals were accepted by David Cameron’s government in 2014 but funding was not agreed until nine years later. “One of the things that could have potentially meant, [so] that what happened at the Countess of Chester was spotted earlier and the dots were joined up, would have been having medical examiners,” Hunt said.
The senior Tory MP said he accepted the proposal for medical examiners in 2014 and commissioned a pilot study between 2016 and 2018. However, he said the scheme was never funded until it crossed his desk at the Treasury in 2023 when he was chancellor.
Hunt added: “I think it’s something I look at as being one of the things we took too long to implement.”
Giving evidence at Liverpool town hall, Hunt said cases of intentional harm in the NHS are not spotted as soon as they should be owing to a failure to properly address the thousands of preventable deaths each year.
Patient Safety Watch, a group chaired by Hunt, estimates there are about 13,500 preventable deaths every year in the NHS. Part of the problem, he said, was a “culture” of clinicians feeling as if they would not be supported by the NHS when involved in cases of preventable death.
“When you have the egregious cases – the Shipmans or the Letbys – they’re less likely to be spotted when there’s so much preventable death going on,” Hunt said. “At the same time it’s important [for] medical examiners that tragically, once in a while, there will be malicious actors and you have to have that in the back of your mind the whole time.
“But they would become much more apparent, more quickly if we had a much better structure of preventable deaths which are caused by people who are really trying their hardest.”
The inquiry, which began in September, is due to hear its final evidence next week before producing a report at the end of 2025.
Source: theguardian.com
