On Friday the latest edition of the BMJ was posted through our front door. The headline in capitals and in bold was ‘ALARMS IGNORED’. This edition of the journal explored what the ‘Letby case  reveals about major institutional failures’.

Institutions, both NHS and professional, must make a conscious effort not to immediately act defensively to any suggestion that something may be going wrong. Repeated experience indicates that they are not currently successful in this as described in this BMJ editorial:

My own personal experience, before I retired as an NHS psychiatrist, has been in attempting to share concerns in relation to safety issues associated with psychiatric interventions. I found that the response from the Royal College of Psychiatrists was to do everything it could to ignore my concerns. I am aware that I am far from alone in this experience with the college.