00:00The report describes dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals
00:11of safeguarding.
00:14Errors were made by nurses, doctors and managers at the time of these events. I've set these out in the
00:20report and will turn to this topic later.
00:25There was also complete failure at all levels to invoke safeguarding procedures at any point.
00:32Looking for clinical or other explanations for deaths and collapses was not wrong, but once there was suspicion that Letby
00:40may be causing harm deliberately, safeguarding steps should have been taken.
00:47She should have been removed from the ward as a neutral act, and matters could have been investigated without risk
00:54to babies.
00:57No one seems to have thought that safeguarding action is required when a member of staff has suspected of causing
01:03deliberate harm.
Comments