We have all seen the image of Lucy Letby in her nurse’s uniform smiling as she holds up a babygrow. The use of this image has sparked debates between social media users. Many think that her mugshot should be used instead.

One user complained, “Can we start using her mug shot instead of this fake smiley faced photo holding a baby onesie”, while another responded, “No, this is 100% the right one to show. People still don’t understand that monsters look, walk and talk like non-monsters and later are shocked because ‘oh she was such a kind nurse’”. I am inclined to agree with this latter view. The photo reminds us that we can never ‘know’ what a murderer looks like.

“The photo reminds us that we can never ‘know’ what a murderer looks like”

What is it about Letby that shocks us so much? Her job? Her gender? Her race? Our biases, both unconscious and conscious, make us believe that she is not a killer. I doubt anyone thought James Bulger’s ten-year old killers ‘looked’ like murderers or Harold Shipman. It is why there is an obsession with the coverage of these type of crime cases. We struggle to believe that someone who appears ‘normal’ could also commit the unimaginable.

This disbelief is harmful. In Letby’s case, it caused delays and thwarted opinion. Lives could have been saved if the consultants who repeatedly raised concerns had been listened to sooner. The fact that she was only removed from the ward a year after the first deaths occurred (and even then had access to sensitive patient documents), and was not suspended until mid-2018, reveals serious failings in hospital management. Much of this, I think, is due to our ideas about what a murderer looks like.

When Dr Brearey, the neonatal ward’s lead consultant, first sat down with Unit Manager Eirian Powell and Director of Nursing Alison Kelly to discuss the spike in unexpected deaths, he recalls saying, “Oh no, it can’t be Lucy. Not nice Lucy”. You would forgive him for having this immediate reaction. Letby was a well-liked, dedicated nurse who “knew her stuff” – she doesn’t fit the image of a murderer created for us by popular culture.

Nevertheless, it only took a matter of months for him to overcome his disbelief that “nice Lucy” could be the perpetrator, turning his attention to the evidence and the babies’ safety. Why didn’t hospital management do the same? Certainly, it was hard to believe that one of their own could be behind the tragedies, but scrutinising every possible cause is of the utmost importance in such a high-stakes job. While we generally agree that someone is innocent until proven guilty, this mindset has limitations when vulnerable lives are at stake.

Images were pertinent to the hospital management’s delay in dealing with the consultants’ concerns. Not only did Letby not fit the hospital’s image of a serial killer, but management was further perturbed by the prospect of damage such a case would have on their image. It is understandable that they didn’t want to take the case to the police immediately, conducting internal reviews to protect the hospital and staff concerned. However, BBC reports have revealed that they failed to conduct further external reviews, despite being advised that they should.

“Management was further perturbed by the prospect of damage such a case would have on their image”

This, considered alongside the fact that consultants were warned off going to the police due to the catastrophic consequences it would have for the hospital and their careers, suggests that management were more concerned about saving face than patients’ lives.

Both Dr Brearey and Dr Gilby, Ian Harvey’s replacement, agree. Dr Gilby argued, “Protecting their reputation was a big factor in how people responded to the concerns raised”, while Dr Brearey believes their fear of reputational damage led them to “engineer a narrative” to avoid calling the police. They worried that this “would turn the neonatal unit into a crime scene”, yet that’s exactly what it was.

The Letby case has raised concerns about both this specific example of hospital mismanagement, with calls for Chester Police to “investigate hospital bosses for corporate manslaughter”, and hospital management more widely. It clearly needs to change. Numerous industry experts have expressed their outrage in letters to The Times, with the case being called “yet another report of unregulated NHS hospital managers allegedly obstructing whistleblowers”.

The recurring theme in these complaints is the need for independent regulation of hospital management. Many of the managers in Letby’s case were under the GMC or NMC, but these councils’ power only pertains to their fitness to practice, having little effect on their management powers. We clearly need a separate regulatory body specifically for NHS management to prevent the reoccurrence of such horrific events. As one letter stated, “The Lucy Letby case must now bring the NHS management gravy train to a shuddering halt”. Letby is not the only one with blood on her hands.