Nick Triggle
Health correspondent

As part of its work, the Thirlwall inquiry has been looking at why the lessons of previous inquiries have not been learned.

As referred to in our last post, it says most recommendations from former inquires have not been implemented - and, when they have, it has taken too long or progress has not been tracked.

It blames a lack of political will and disruption caused by repeated structural reorganisations.

This, the inquiry suggests, had a potentially significant impact here. It cites the medical examiner system - whereby an independent doctor looks into deaths that are not reviewed by a coroner so that it is not all down to the treating doctor to sign off.

The move was recommended in 2003 by the inquiry into the Harold Shipman murders, and called for again, a decade later, as part of the inquiry into the failings at Mid Staffordshire NHS Trust. But it took until 2024 for it to be introduced.

Former Health Secretary Jeremy Hunt told the inquiry he believes it would have prevented a number of deaths at the Countess of Chester, if it had been in place sooner.

Judith Moritz
Reporting from Liverpool

One feature of Lady Justice Thirlwall’s work is that her inquiry has looked further than just the situation at the Countess of Chester Hospital.

Her team has analysed previous public inquiries into more than 30 past NHS scandals from the past 30 years - including the cases of Dr Harold Shipman and nurse Beverley Allitt.

They have discovered that the majority of recommendations made by all those inquiry reports have not been implemented.

There is a groundswell of opinion from the families of babies in the Letby case that the Thirlwall report must be different. They want the recommendations which are made here to be enforced.

Here's a reminder of what we've learnt from Thirlwall's report.

Key findings:

• The deaths and near-deaths of some babies who were attacked by Lucy Letby could have been prevented if safeguarding practices had been followed
• There was a “profound failure of management, governance and safeguarding” at the Countess of Chester Hospital
• A "reprehensible" lack of consideration was shown to the parents of babies attacked by Letby

Key recommendations:

• In all neonatal units, cots and incubators should be fitted with CCTV
• Access to insulin should be restricted
• IT systems within the NHS should be harmonised

You can read more about Thirlwall's recommendations here. For our reporter's take on what the fallout from the inquiry might look like, click here.

Image source, Getty Images

Lucy Letby's barrister Mark McDonald tells the BBC the inquiry was launched "too soon" and "proceeded on the wrong premise" that Letby is guilty, meaning it is now "tainted".

This is because, he says, "Lucy Letby is innocent".

McDonald acknowledges families will find the debate around Letby's innocence "distressing", but says: "We are all after the truth and if the truth is that Lucy Letby is innocent then surely everybody needs to know that."

As a reminder, Letby is serving 15 whole-life prison terms for murdering seven babies and attempting to murder seven others, including one baby whom she tried to murder twice.

On two occasions, Letby has been denied permission to appeal against her convictions.

Michael Buchanan
Social affairs correspondent

Susan Gilby was appointed chief executive of the Countess of Chester trust in September 2018.

She was suspended in December 2022, and was awarded £1.4m in damages after suing the health service for unfair dismissal.

At the time, Gilby had accused the trust's chairman, Ian Haythornthwaite, of bullying and harassment.

Now, in her reaction to the report, she says she found the trust "utterly dysfunctional, very hierarchical and not an organisation that was prepared to look in on itself".

She acknowledges that her "greatest fear" when she started at the organisation was that some of the deaths could have been prevented.

“Patient safety is non-negotiable, it should be the first thing you are asking yourself when you are making a decision, whether it's an investment or an efficiency cut – what is the impact here on patient safety? Is there a possibility here that patients could come to harm?" she says.

"What I found when I arrived in 2018 was that that question wasn’t even asked," she continues, saying there was a "total lack of curiosity and concern" about patient safety.

Nick Triggle
Health correspondent

I posted earlier on how the wider NHS culture contributed to the failings at the Countess of Chester. There is much more in the report about this.

The revelations about how failing managers are treated, makes for particularly damning reading.

It says there is a consistent inability within the NHS to deal with poor performance. Failing managers will be moved, the inquiry heard, often with the active assistance of NHS England, in a process referred to as rehabilitation.

Countess of Chester chief executive Tony Chambers referred to it as "the donkey sanctuary".

The report even notes how some failing managers receive pay-offs and move on "with few questions asked" as individual NHS trusts worry about the threat of employment tribunals.

The inquiry says while there are many excellent managers in the NHS, profound change is needed in the way the NHS deals with those who fail.

Former senior managers at the Countess of Chester Hospital, who had spoken at the inquiry, issued a joint statement following the publication of its findings, saying they are "carefully reviewing" the report and its recommendations.

“Given that there are a number of investigations under way, and that the work of the Criminal Cases Review Commission has not yet completed, it would be inappropriate for us to offer any further comment at this time," say Sue Hodkinson, Alison Kelly, Ian Harvey and Tony Chambers.

“Our thoughts remain with the families affected by the tragic events that took place at the Countess of Chester Hospital.”

The four were, respectively, the hospital's HR director, nursing manager and safeguarding lead, medical director, and chief executive when Letby worked there.

The chairman of the British Medical Association (BMA) council says the events at Countess of Chester hospital from 2015-2016 were “some of the most appalling” in recent NHS history.

Dr Tom Dolphin says major reforms are needed to NHS culture and safeguarding.

“Whistleblowers in the NHS deserve strong protections, and the inquiry makes it clear that these doctors did not get them,” he says.

"We have represented many whistleblowers who have been silenced by management for raising safety concerns and who have suffered career-ending consequences."

Going forward, he says non-medical managers need to be held accountable and regulated, and welcomes the reports recommendation of a full statutory regulation system.

Image source, UK Parliament

Turning back briefly to the House of Commons, we've been listening to shadow health secretary Damian Hinds, who asked Yvette Cooper questions on the report after her statement.

He says the task now for the NHS, the state and parliamentarians is to ensure "reliable guards against such tragedy happening again".

He says he understands that the government cannot accept all recommendations in full at this stage, but asks when the government's full response will come.

Hinds raises how the report says there are still many NHS staff who don't feel able to raise concerns without risking their career. "What else can be done to establish independent escalation pathways?" he asks Cooper.

The shadow health secretary later asks what Cooper's initial assessment is on how to implement their plans to introduce cot cams.

Cooper says the government's full response will be published "within six months" and says she plans to review the details of current system investigating patient safety concerns.

We've just heard from the NHS trust which runs the Countess of Chester Hospital where Lucy Letby carried out her crimes. Here is the statement from its chief executive, Jane Tomkinson, in full:

“Today, as the Thirlwall report is published, our thoughts remain fully with all of the families and the babies who came to harm or who died because of Lucy Letby’s crimes at the Countess of Chester Hospital in 2015 and 2016. We recognise the enduring impact on them and the courage and dignity they have shown in ensuring their experiences are heard.

“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.

“We acknowledge however that there is more to be done. We will now carefully consider the entire content of the Thirlwall Report and its recommendations, working with NHS colleagues to embed the learning locally and across the wider NHS. Our priority is to ensure that we address the Thirlwall Report’s recommendations as swiftly as possible, whether through ensuring that actions we have already taken are sustained or by taking further action where needed.

“We recognise the contributions of the families and everyone who gave evidence, including many of our staff. We have cooperated openly and fully with the Thirlwall Inquiry, and we are grateful to Lady Justice Thirlwall and her team for the diligence and care with which they have conducted the Inquiry.

“We are proud of our staff and their commitment to providing high-quality patient care. They are the heart of our organisation, and their professionalism, compassion and resilience are central to the care we provide to patients every day.

“What took place at the Countess of Chester Hospital NHS Foundation Trust in 2015 and 2016 and the impact it had on so many people will not be forgotten. We will always remember.”

The health secretary continues to respond to the recommendations of the report, and says the Department of Health will set up a new hub to track progress of the implementation of recommendations from inquiries, "not just for this inquiry, but for others, right across the NHS".

She says she is going to discuss with the maternity task force plans to introduce a new Maternity and Neonatal Commissioner to address serious concerns around standards.

She will meet Lady Justice Thirlwall to discuss how to take the conclusions of the report forward.

"The safety and safeguarding and wellbeing of babies must never again be treated as a side issue," she says finishing her statement, adding: "This must be a turning point for the NHS."

Cooper says she is taking the recommendations seriously, and the government will consider the full report and set out a full response.

She says she has asked officials to "urgently develop plans for cot cams".

On safeguarding, a revised framework published in 2026 will be "urgently reviewed" in light of the report, the health secretary says. "I will not hesitate to hold the NHS to account for the highest standards at every level," she adds.

Cooper also agrees with the finding that the guidance on sudden unexpected death in infancy should be updated. "That is now under way," she says.

She also says she agrees with the recommendation to go further on stronger controls on insulin storage.

• The inquiry recommended the implementation of CCTV in all cots and incubators in all neonatal units

Image source, UK Parliament

Yvette Copper references the report's findings of "failure at all levels to invoke safeguarding procedures at any point".

She highlights the "appalling" finding of an "exercise in spin" to steer away from referral to the police, instead of putting the safety of babies first.

The hospital trust repeatedly failed the parents, in failing to keep their beloved babies safe, she says.

"The suffering endured by these babies and their families is impossible to comprehend."

"On behalf of the government, and the health service, I am profoundly sorry for the failures set out so clearly in this report. For the harm, distress and unthinkable loss for their families, and for the failures to keep their babies safe."

Health Secretary Yvette Cooper says the report is both "thorough" and "devastating" and she "can't begin to fathom the grief" that the affected families are feeling, and recognises they have waited "many years" for this report.

"The report sets out a dispiriting and at times shocking account of multiple repeated mistakes and failings by organisations and individuals," Cooper tells the Commons, quoting the inquiry chair.

She describes "shocking failures" mentioned in the report - such as a failure to put the safety of babies first, of safeguarding, in governance and regulation, in the "most basic duty of candour," in "professional curiosity" and a "repeated failure" to refer concerns to the police.

Thirlwall comes to a "devastating conclusion" that some babies would have been saved if earlier action was taken, Cooper says.

We're expecting to hear from Health Secretary Yvette Cooper shortly, who will make a statement on the final report and recommendations from the Thirlwall Inquiry.

We'll be following live here and be bringing you key lines - you can watch at the top of the page.

The Care Quality Commission (CQC) has apologised for the “significant shortfalls” in its document management which affected the evidence it could provide for the Thirlwall Inquiry.

The regulator’s chief inspector of hospitals says an independent external review of its information and records management practices has since been undertaken to improve its systems.

Dr Toli Onon says “crucial information” was not shared by the Countess of Chester during the 2016 CQC inspection of the hospital, but that the commission as a regulator did not take a “sufficiently investigative and inquiring” approach.

The chief inspector says it has changed its assessment approach and is committed to working with the government and other partners to take forward the recommendations set out in the report.

“Everyone who has a role in delivering, leading or regulating healthcare services must actively consider the findings of this report to help prevent another situation where premeditated harm goes undetected,” she says.

Image source, CQC

This post contains distressing details.

Lucy Letby, 36, is the most prolific child killer in British legal history.

She is serving 15 whole-life prison terms for murdering seven babies and attempting to murder seven others, including one baby whom she tried to murder twice.

Her trial revealed she lived an unremarkable life before her arrest in July 2018.

Letby was present at a series of "unexplained" deaths and sudden collapses of vulnerable babies on the neonatal unit at the Countess of Chester Hospital.

The list of charges she faced focused on the period between June 2015 and June 2016, when Letby was removed from frontline duties.

Letby deliberately injected babies with air, force fed others milk and poisoned two of the infants with insulin.

In 2023, the then 33-year-old was convicted of seven murders and six attempted murders, with not guilty verdicts on two counts of attempted murder.

The jury was deadlocked on another six counts. After a retrial in July 2024, she was convicted of a further count of attempted murder.

Cheshire Police says it will now "carefully review" the contents of the Thirlwall Inquiry report and "fully consider" relevant recommendations in light of ongoing investigations.

In a statement, the force says following the trial and conviction of Lucy Letby, it launched Operation Duet - an investigation into corporate manslaughter at the Countess of Chester Hospital.

The investigation focuses on senior leadership and decision making, to determine if any criminality has taken place.

In March 2025 the scope of the investigation widened to also include gross negligence manslaughter, it adds.

Four people remain on bail who were arrested as part of the investigation.

The force says both manslaughter elements of the investigation are continuing and its thoughts remain with the families of the babies.

Justice Thirlwall's report "paints a damning picture of what happens when concerns over patient safety are not listened to or acted on", a solicitor representing seven of the families says.

Speaking outside Liverpool Town Hall, Tamlin Bolton says many "continue to live with the consequences of what happened to their children".

Bolton highlights several failures at the Countess of Chester Hospital, including in "safeguarding, governance and oversight".

"To the extent that the executives thought about the parents at all, they considered it better to say nothing in the belief a police investigation would go nowhere," she adds.

The report and its criticisms, she adds, "cannot be the end of this matter".

"Those responsible for patient safety must ensure that the lessons learned are translated into meaningful and lasting change," Bolton says.

Shortly after, Bond Turner solicitor Carla Duprey, who represents two families, says "the importance of these findings cannot be overstated", but says it will take time to properly consider its conclusions before commenting further.

As a reminder, the identities of the victims and their families have not been made public due to a court order in place to keep them anonymous.

Erica Witherington
Reporting from Liverpool

While delivering her statement, Lady Justice Thirlwall pointed out findings about specific staff members at the Countess of Chester hospital.

Thirlwall said that "from the outset", director of nursing and head of safeguarding Alison Kelly and medical director Ian Harvey "dismissed the idea that Letby was deliberately harming babies".

"They did not believe it," she said, pointing out that when hospital chief executive Tony Chambers became aware of what was happening on the unit - only after the deaths of the two final babies in this case, babies O and P in June 2016 - he did not believe it was Letby either.

But Thirlwall said whether these managers believed Letby was harming babies or not was "irrelevant".

She said they should have taken action.

Thirlwall highlighted a remark that Chambers made in his first meeting with the consultants who were concerned that Letby might be attacking babies: "That would be convenient," he said, according to Thirlwall.

Thirlwall called this "offensive", and said he added to the "unnecessary delay" in calling the police.