children. the government held an inquiry into what had gone wrong at the hospital. the report came out in 1994 and it is identified a number of failings of what central finding was because every death and klutz could have another initial expedition and because nobody could believe that a colleague could deliberately harm children and babies, the nurse was able to continue in the unit for two months. the parallels with lucy letby are striking. senior colleagues did raise concerns about her, those in charge were apparently unable to believe there might be a killer in the hospital. so how can the nhs take that mindset into account for the future? we take that mindset into account for the future? the future? we should have had a s stem the future? we should have had a system for the future? we should have had a system for looking the future? we should have had a system for looking at the future? we should have had a system for looking at the - the future? we should have had a | syst