No doubt, this is the question concerning staff and management of the Countess of Chester Hospital when they were faced with the disturbing realisation that their hospital had the highest death rate in vulnerable babies than other hospitals in the country.

Even with the best care, sadly babies born prematurely don’t always make it but at this hospital where the rates were historically 1 -3 per year shot up to eight in 2015 and five in 2016.

Rightly, the hospital carried out its own investigation but was unable to determine the cause. The Royal College of Paediatrics and Child Health issued a statement to say there was no ‘definitive explanation’ for this death rate. However, ‘significant gaps’ in nursing rotas, ‘poor decision making’ and ‘insufficient senior cover’ was found.

The Care Quality Commission found that in 2016 nursing staff levels did not meet the required standards.

The hospital called in the police to investigate and this has led to a nurse being arrested on suspicion of murder of eight babies and of the attempted murder of six. However the police probe is looking into a total of 17 deaths and 15 non-fatal collapses.

To my knowledge this nurse has not been charged (as yet) with any offence.

The hospital stopped neonatal care involving babies born under 32 weeks gestation from July 2017. We will have to see what unfolds in the coming weeks and months but what seems certain is that there will be lessons to be learnt.

Preventing harm is the strategy which will reduce claims and the cost to the NHS; but those who have suffered have a right to find out what happened to them with a robust and transparent investigation. If appropriate, changes can be made from that learning and a duty to ensure that the injured person receives just compensation to allow them to receive funds to live a dignified and fulfilling life where harm has deprived them of this.