launched. ,., ., ., ., ,., launched. good morning. the reason was that it was launched. good morning. the reason was that it was discovered launched. good morning. the reason was that it was discovered there - launched. good morning. the reason was that it was discovered there was| was that it was discovered there was a high level of mortality at this hospital, which couldn t really be explained. it turned out the figures had been dismissed. eventually the relatives of deceased people mounted a huge protest. as a result of that, an inquiry was held, which uncovered many aspects of weakness in leadership, failure to give priority to patients as opposed to targets. and a number of other issues, which led to me having to make 290 recommendations for changing things, principal being the duty of candour, with professionals and hospitals needing to be open and frank about things that had gone wrong, but also a culture whereby, when things had
determined to cause harm, systems may never be able to stop that. again, doctor harold shipman, the beginning of the 20005, convicted of killing 15 patients at, again an independent inquiry, that had six or seven report5 independent inquiry, that had six or seven reports over a number of years, looking at his actions, the fact he may have killed over 200 people, that inquiry found. the question i get is speed versus detail, and compelling people. the government said in this case it wants a quicker inquiry. i guess. we are expecting the sentencing, but again questions as to why lucy letby will not be appearing. yes. again questions as to why lucy letby will not be appearing. will not be appearing. yes. i mean, the issue there will not be appearing. yes. i mean, the issue there is will not be appearing. yes. i mean, the issue there is it s will not be appearing. yes. i mean, the issue there is it s her will not be appearing. yes. i mean, the issue there is it s her choice, i t
somehow grade is should this have a higher status, should this be a statutory inquiry? the question that some have raised. it would mean people would be compelled to produce evidence to the inquiry. the flip of that, the government said that is much more complicated, takes much longer, and means the lessons learned take more time to feed through into the system. if you think back, there are precedents to this. in 1991, nurse beverley alex, she was convicted of killing four children. and harming seven others. beverley allitt. the independent inquiry reported within a year and came back with a dozen recommendations. that inquiry did say that if there was someone
soon enough. the whether it could have been stopped soon enough- whether it could have been stopped soon enough. the important thing is somethin: soon enough. the important thing is something like soon enough. the important thing is something like this soon enough. the important thing is something like this must soon enough. the important thing is something like this must never - something like this must never happen again and the nhs must learn lessons. that s why the government is launching an inquiry to make sure all the lessons that can be learned will be learned and that all possible action is taken so this can never happen again. possible action is taken so this can never happen again. letby, a nurse in charue never happen again. letby, a nurse in charge of never happen again. letby, a nurse in charge of the never happen again. letby, a nurse in charge of the most never happen again. letby, a nurse in charge of the most vulnerable i in charge of the most vulnerable a
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