If anything shows the problem here (and this is not a criticism of the individuals involved so much at is the system) its that senior consultants, when they had a well-founded and shared belief that a colleague was killing people, went to the management rather than the relevant authorities.
Their hands were tied after they'd been forced to sign an apology to her. Had one of them then gone to the police it might have painted them in a very negative and bloodthirsty light. Imagine how bad it could have looked if all seven went. Could a consultant have encouraged a nurse to blow the whistle? Again what happens if that comes to the fore.
One of the questions for me at the moment is, the execs at the hospital that backed her against the consultants, were all no longer there some 12 months later. Did they all get promotions? Took sideways steps? Retired? How did that happen.
I'm speculating now, did the consultants complain about the involvement of the execs when it came to letby (or someone or something else for that matter)? was there a managerial merry-go-round to clear the air? Again I alluded to this earlier - how was she allowed to stay on the ward under those same consultants. Without working in it, and so knowing for sure, it seems the working environment was toxic and that becomes oppressive eventually. What was the turnover of staff like, anyone retired with good or bad memories of the place for instance. I'd expect any loss of life on such units to be devastating to all involved, that this particular unit had such worryingly high numbers of mortality rates (want to be more delicate than that here but am mildly hung over*) that the atmosphere must have been gloomy. The worry for the babies and the possibility of yet more devastated families is more than anxiety inducing.
There's means in other workplaces for anonymous whistle blowing, I expect there is in the nhs, there was concern enough from a group of consultants and no one else?
There'll be more to consider yet. Tragically sad.