NHS patients’ lives will continue to be “at risk” unless whistleblowing laws are changed in the wake of missed chances to catch killer nurse Lucy Letby, the health service ombudsman has told Sky News.

Executives at the Countess of Chester Hospital, where Letby worked, failed to act on repeated concerns raised about her by doctors who linked the neonatal nurse to a growing number of unexplained deaths.

The government has announced an inquiry into how Letby was able to murder seven babies and attempt to kill six others.

Speaking in the wake of the case, Ombudsman Rob Behrens warned: “We know that routinely 11,000 people die avoidably each year in the NHS.

“We know that the NHS spends millions of pounds in litigation in cases involving perinatal death and other forms of mortality in the NHS.

“And so, it’s going to continue to happen unless everyone gets together under the leadership of ministers to address these issues. And there are no quick fixes.

“There needs to be changes to the law to enable whistleblowers not to be fobbed off and threatened in the way that happened in this case.”

Mr Behrens said concerns raised about Letby were not acted on because of a “defensive culture” in the NHS which puts “the reputation of the trust above patient safety”.

He said: “We’ve seen it too many times. In too many places, where clinicians are stigmatised because they want to raise patient safety issues.

“And instead of being listened to time and again, what happens is that they are bullied, threatened, and then ultimately reported to the regulatory body the GMC in a disciplinary way.”

He added: “There is a culture which puts the reputation of trust in the NHS above the issue of patient safety.

“And turning that round is immensely difficult, but it is there and we have to learn from disclosures, by clinicians, by managers, by independent reports, principally by users of the service, by patients.

“And what is of great concern to me, as well as the adversarial culture which exists, is that we know that too many times, families and patients are not listened to. And there’s a lack of empathy and compassion”.

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Mr Behrens has written to the health secretary to add his voice to those, including bereaved families, calling for the inquiry into the Letby case to be a statutory inquiry. where witnesses would be compelled to give evidence.

He has yet to receive a reply and is not confident of receiving a response from Steve Barclay.

Mr Behrens is not convinced a report into the failings at the Countess of Chester Hospital will prevent a repeat of yet another maternity scandal in the future, unless swift action is taken to enforce systemic change.

Since 2015, three major inquiries have exposed the catastrophic failures that led to babies being harmed or dying at the Morecambe Bay, Shrewsbury and Telford and East Kent NHS hospital trusts.

A fourth inquiry into the Nottingham hospital trust is now under way.

“I think that just commissioning reports and hoping they will be implemented is not the answer,” he said.

“I think Bill Kirkup has made that clear from his report into East Kent, where he’s basically saying things that happened 15 years ago which he reported on in Morecambe Bay and nothing has changed.

“So this is about the leadership of the NHS, ministers, boards, managers, NHS England, not sufficiently addressing the culture and what is necessary to deal with that transformation.

“I’m not interested in blame. You know, the courts are about blame. They’ve done that in the Letby case.

“What I want to see happen is that there is learning from the fact that here and elsewhere, the board failed to intervene when they had the opportunity to do so, that senior managers had the mindset that the way to deal with this was to say no, this is not an issue.”