The final report from the Thirlwall inquiry into the case of serial child killer Lucy Letby has identified significant systemic failings within the broader National Health Service (NHS) in England, extending beyond the specific failings at the Countess of Chester Hospital. The inquiry found that the culture within the health system created an environment where poor care, and in this instance, criminality, could go unchecked for an extended period.
The report, comprising over 200 pages, details how issues ranging from regulation and employment practices to the NHS's and government's ability to learn from past mistakes contributed to the enabling conditions for Letby's actions. Health Secretary Yvette Cooper stated that she "will not hesitate" to hold the system accountable at all levels and has pledged to establish a hub to monitor the implementation of the inquiry's recommendations. A new post for a maternity and neonatal commissioner has also been created as part of the commitment to improving standards, which Cooper described as a "turning point for the NHS."
Overemphasis on Reputation Management
The inquiry highlighted an "over-focus on process and reputation management" among NHS managers, leading to a reluctance to admit fault. This phenomenon, described by one witness as "blame engineering," was identified as a key factor in how managers at the Countess of Chester approached the Letby case, with the report characterizing some actions as an "exercise in spin." This management approach makes it difficult for staff to raise concerns, a recurring issue highlighted in numerous past inquiries.
Despite initiatives like the Freedom to Speak Up program, which aims to support staff raising concerns, the report suggests that in many areas, it has become a "box ticking" exercise. This has contributed to a "toxic negativity" surrounding whistleblowing, discouraging staff from speaking out, a sentiment echoed in declining confidence levels in speaking out shown in NHS staff surveys.
Ineffective Management of Poor Performance
The Thirlwall inquiry also pointed to a consistent inability within the NHS to adequately address poor performance among managers. The report noted that failing managers are often reassigned, sometimes with assistance from NHS England, a process referred to as rehabilitation. The former chief executive of the Countess of Chester, Tony Chambers, reportedly called this the "donkey sanctuary." The inquiry observed that some underperforming managers receive severance packages and move to other positions with minimal scrutiny, partly due to trusts' concerns about potential employment tribunals.
While acknowledging the presence of many capable managers, the inquiry stressed the need for profound change in how the NHS handles underperformance. The government's proposed barring service, intended to prevent unfit individuals from working in healthcare, could be undermined if the system continues to overlook such issues, the report warned.
Regulatory Shortcomings
Regulation was also identified as a significant area of weakness. The Care Quality Commission (CQC) inspected the Countess of Chester in February 2016, months after Letby's attacks had occurred. Despite key information being withheld from inspectors, the regulator was criticized for not demonstrating sufficient curiosity to investigate beyond the information provided. This occurred despite a warning from a previous inquiry into baby deaths at the Morecambe Bay NHS Trust a year earlier, which advised the CQC to adopt a more robust approach.
Weaknesses in regulatory oversight have persisted, with an independent review in 2024 indicating a deterioration in the CQC's ability to identify poor performance. The CQC has acknowledged its lack of investigative rigor in 2016 but stated that its approach has since been strengthened. Additionally, the Nursing and Midwifery Council (NMC), which oversees nurses, was found to have been insufficiently curious. The NMC renewed Letby's registration at a time when she was restricted from working on a ward and was under police investigation.
Failure to Learn from Past Scandals
The inquiry also examined why lessons from previous scandals have not been effectively learned. Despite decades of inquiries and thousands of recommendations dating back 30 years, the report found that most have not been implemented, or implementation has been excessively slow and untracked. Factors contributing to this include a lack of political will and disruptions from frequent structural reorganizations within the NHS.
The report suggested this failure to learn had a tangible impact on the Letby case. For instance, the introduction of the medical examiner system, where an independent doctor reviews deaths not subject to coroner inquests, was recommended in 2003 following the Harold Shipman murders and again in 2013 after the Mid Staffordshire NHS Trust failings. It was not implemented until 2024. Former health secretary Sir Jeremy Hunt suggested to the inquiry that its earlier implementation could have prevented some of the deaths at the Countess of Chester.
