No sooner had British nurse Lucy Letby been sentenced to life in prison for the murder of seven babies and the attempted murder of six more, than the blame game began. Perhaps I should say blame games, as everyone sought to find fault with everyone else. The media of course rushed to judgment; it was obvious to them that the hospital management was to blame. “NHS management is a bullying, incompetent cult,” claimed the Daily Telegraph, ending: “If its managers remain untouchable, how long before there’s another Lucy Letby?”

The doctors’ union, the British Medical Association, was also quick to weigh in. “We have long called for non-clinical managers in the NHS and other health service providers to be regulated, in line with the manner in which clinical staff are by professional bodies,” said Professor Phil Banfield, BMA Chair of Council, in response to the Letby verdict. 

The BMA conveniently forgets that the nurse and her colleagues were indeed regulated, as were the director of nursing and medical director, and (in this particular hospital) the chief executive and divisional director. All were qualified and regulated doctors or nurses; not, as the media and unions would have us to believe, “untouchable” managers.

There were a few wiser and more measured comments. A columnist from The Guardian observed that “Registering all managers might be a good idea but it might also be yet another regulation added after every scandal, never re-examined to see if patients became safer. Nor does professional registration protect against bad practice.”

She is right; professional regulation does not protect against bad practice. The pediatricians in the hospital where Letby worked raised their concerns informally and then formally three years before she was arrested. They also reported the medical director and director of nursing, both of whom had dismissed their evidence about Letby, to their respective professional regulators.

After a brief inquiry, the doctors’ regulator dismissed the complaint and subsequently allowed the medical director to voluntarily relinquish his license. The nursing regulator opened a file but took no action for three years while the police were investigating. It has now started its inquiries and has said it will look at the conduct of other nurses in the hospital. The medical regulator is, it seems, happy to let sleeping doctors lie.

In engineering, the risk of a “single point of failure” – the failure of a single component resulting in a cascade of other events leading to catastrophic disaster – is well understood. But this was not that. In this ward, this hospital, this management, there seem to have been multiple points of failure, as so often happens when human beings are involved. Trying to pin the blame on one element, as the media and the BMA have done, is the classic error of prescribing a solution before understanding the problem.

Of course, there will now be a public inquiry so we will learn more about what went wrong than we have already from the evidence at nurse Letby’s trial. Let’s hope it is not as pointless as the public inquiry into six murders in Ontario care homes by nurse Elizabeth Wettlaufer.

That inquiry concluded, in four volumes, that no one was to blame – not even the nursing regulator which had failed to notice that she had lied frequently on her annual renewal form. The regulator’s register was not integrated with its internal complaints database, nor did the registration and complaints staff ask questions of each other. In the end, Wettlaufer was only identified because she confessed, not because the regulator noticed that she lied.

Mention of Wettlaufer reminds us that murdering nurses may be found anywhere. A quick search finds examples from the U.S., Germany, Norway, and Czechoslovakia as well as Canada and the U.K. Such criminals are rare but not unique and there seem to be some similarities in the methods used, the vulnerability of their victims – babies or seniors – and their ability to manipulate their colleagues into thinking well of them.

There is no doubt that many things went wrong with the response of people in the hospital: the regulated nurses who worked alongside nurse Letby but apparently saw nothing; the ward manager who refused to listen to the pediatricians; the nursing and medical directors who brushed off their concerns; the human resources team who saw the well-mannered and hard-working nurse as the victim of dominant doctors and actually demanded that they apologize to her; and of course, worst of all, the refusal of hospital management to engage with the families whose babies were murdered or harmed.

I sometimes think regulators have only themselves to blame for overselling regulation. What an odd argument it is that because regulation has failed to stop this nurse’s crimes, even more people need to be regulated. If regulation has failed, more of the same is hardly a solution.

In the end, the families are left with grief and anger and frustration at the failure of the entire system to do no harm.

Harry Cayton is a sought-after global authority on regulatory practices who created the Professional Standards Authority (PSA) and pioneered right-touch regulation. He is a regular Ascend Voices contributor.