In the aftermath of the verdict that Lucy Letby murdered and attempted to murder so many newborn babies in her care, questions need to be addressed.
It appears that the correct channels were used by the consultant Paediatrician at the Countess of Chester Hospital when they raised concerns about their colleague.
The internal investigation by The Countess concluded that the doctor's concerns were unjustified, and the Paediatricians were told to draw a line under the 'Lucy issue' and to apologise to Lucy for victimisation.
This led to a two-year delay in the hospital notifying the police of the concerns before they asked the police to investigate the matter when all other explanations for the continued deaths and harm were exhausted.
Dr Jayram is reported by ITV News to express the view that he genuinely believed that there are four or five babies who could be going to school now who aren't.
As more and more details emerge about the case, the worrying wider picture emerging is of a Health Trust that appeared to be more concerned with protecting its reputation rather than the safety of the patients in its care.
The failure of an institution to address any allegations adequately and in a transparent way can seriously undermine the public's trust in the institution.
Full accountability and transparency are paramount to ensuring suspicions are thoroughly investigated and patient safety is maintained.
At Graystons Solicitors, we are very concerned when the culture in hospitals is not as open and accountable as it should be.
Patient safety would be improved if there was a culture of learning from mistakes above all else. Sadly, as a firm that deals solely with medical negligence, we often see tragic consequences of medical failure.
Although we recognise that mistakes will always happen, as we are all human, it is important that we learn from those mistakes to prevent harm to others in the future.