During the ongoing public inquiry into the actions of serial killer nurse Lucy Letby, Karen Townsend, a hospital director, expressed feeling overwhelmed by concerns raised by doctors regarding unexpected neonatal deaths. She revealed that crucial discussions about Letby’s association with these deaths occurred as early as June 2016, yet no police intervention was requested until 2017. Townsend acknowledged her lack of clinical insight and naivety, admitting she relied heavily on the executive team’s management approach. The inquiry has highlighted a problematic culture within the NHS that hindered effective communication and responses to alarming reports about Letby’s conduct.