Things do take an incredible amount of time. Lots of things trigger a need for an internal review (maternity and nicu often share a clinical risk office, I’m only familiar with the maternity side, but examples would be a postpartum haemorrhage, or a severe perineal tear). This then creates a bit of a ‘queue’. Although incidents that involve death or brain damage do get investigated as a priority.The NHS is a huge organisation and must be bureaucratic.
Some might have had their suspicions but how many would jump to ‘someone’s killing babies’. It’s obviously not right but would the bureaucracy delay swift action? After all, it’s basically committees and everyone knows how tangled they can be.
HSIB seem to take about a year to write their reports. These then get given to the trusts to implement their recommendations. Although I doubt the recommendation said “you’re employing a murderer”