The Thirlwall Inquiry report found the collapse and deaths of some babies could have been avoided.

Lady Justice Thirlwall, said: ‘My report describes dysfunctional management and governance; a gulf between hospital leadership and clinicians; and failure to understand the fundamentals of safeguarding.  

‘There was a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital. This was because no-one seems to have understood that safeguarding action is required when a member of staff is suspected of causing deliberate harm and does not require colleagues to be sure of guilt.'

The report finds successive internal and external reviews commissioned by hospital leadership did not address whether deliberate harm was being caused or not, clinicians were made the subject of investigation within Letby's grievance process and parents were kept in the dark for years about what was happening and about the fact that there were concerns their babies may have been deliberately harmed.

The report calls on the NHS to adopt a suspicion of deliberate harm protocol so that managers can no longer refuse to investigate when concerns are raised. 

Seventeen recommendations include fitting baby monitors on all cots and incubators, installing CCTV cameras where insulin is stored and all hospital trusts placing effective mechanisms for board-level monitoring of all deaths of children and babies by 31 March 2027.

Reaction

The Government said it had begun a series of measures in response to the report, including installing ‘cot cams', guidance on the safe use of insulin, a barring scheme for senior leaders who fail in their responsibilities, continued roll out of the national Bereavement Care Pathway for families experiencing neonatal loss and the creation of a single tracker to monitor delivery of recommendations from major maternity and neonatal reviews and inquiries.

Health and social care secretary, Yvette Cooper, said: ‘Safeguarding is everyone's business, and safeguarding must be everyone's priority. Concerns must be heard and acted upon. Staff who speak up must be protected and taken seriously, and I expect every leader, every board across the NHS, every professional and manager, every member of staff, to uphold their safeguarding responsibilities.'

Jane Tomkinson, chief executive at the Countess of Chester Hospital NHS Foundation Trust said: ‘We know that no apology or action can undo what happened at our hospital. We are however truly sorry for the events that occurred in 2015 and 2016. We acknowledge the findings of the Thirlwall Report and will approach its recommendations with openness and a firm commitment to build on the progress we have already made in improving our hospital's governance, safety and culture since that time. We are a different organisation today with new leadership, stronger governance and safety processes, and a more open culture where speaking up is encouraged and acted upon. We firmly believe that the changes we have made, as set out in our evidence to the inquiry, have created a safer environment for our patients and staff.'

Chief nursing officer for England, Duncan Burton, said: ‘This is a hugely significant day in ensuring the NHS accepts and corrects its operational and cultural failings in this devastating case, and the service will now work with Government to carefully consider Lady Thirlwall's findings and recommendations in full and to respond with clear action.'

Chief executive of The NHS Alliance, Sir Ciarán Devane, said: ‘This inquiry is a powerful reminder of the appalling suffering of the families of babies who died as a result of Lucy Letby's crimes, and the wider failures to recognise and act decisively on the warnings.

‘We look forward to working with the Government as it aims to develop a regulatory system for managers that is effective, equitable and fair, and that is fit for purpose for its intended aims.'