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Health Secretary Yvette Cooper has said officials will "urgently develop plans" to introduce live-streaming cameras on England's baby wards after an inquiry into Lucy Letby's murders and attempted murders.
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officials → publish → murders
Inquiry chair Lady Justice Thirlwall called for a series of urgent reforms to neonatal units, including CCTV for all cots and incubators, and restricting access to insulin.
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Thirlwall → call → insulin
Thirlwall said some of the babies Letby killed could have been saved if managers at the Countess of Chester Hospital had taken action earlier.
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managers → say → action
Her report criticises a "complete failure to protect babies" and a "profound failure of management, governance and safeguarding" at the hospital.
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report → criticise → hospital
Thirlwall said 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."
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member → say → guilt
She said it would never be possible to know exactly how many lives could have been saved if safeguarding procedures had been properly followed.
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procedures → say → ?
One of the senior doctors who tried to raise concerns about Letby with hospital managers, consultant paediatrician Dr John Gibbs, now retired, told the BBC the Thirlwall Inquiry report was "grim reading".
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report → try → BBC
In a rare interview he said he accepted that consultants must bear "collective" responsibility for some of the failings identified in the report, and said he wished they had been "brave enough to follow our suspicions and escalate things to the police earlier".
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they → say → police
Chief executive and registrar at the Nursing and Midwifery Council (NMC), Paul Rees, said he was "truly sorry for the NMC's failings" in the Letby case and that "we also did not act quickly enough to suspend Lucy Letby".
Sharing her findings at Liverpool Town Hall, Thirlwall described "dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals of safeguarding".
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Thirlwall → say → safeguarding
Letby was moved on to administrative duties in July 2016 after consultants expressed concerns about her to the hospital's executive team.
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consultants → move → team
But the inquiry has found that alarm bells should have been sounded earlier.
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bells → find → ?
There were several "missed opportunities" for hospital bosses to intervene, the report said, including when three babies died in one cluster in June 2015.
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babies → be → June
Parents of the babies were "kept in the dark for years" over the concerns that their babies might have been deliberately harmed, the inquiry also found.
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inquiry → keep → concerns
Thirlwall described the lack of consideration shown to parents as "reprehensible".
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Thirlwall → describe → parents
Hospital bosses carried out a number of internal reviews into increased infant mortality in 2015 and 2016, but did not invite Cheshire Police to investigate until May 2017.
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bosses → carry → May
Letby remained on site until her arrest more than a year later.
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Letby → remain → arrest
Cheshire Police said it would "carefully review" the contents of the report and "fully consider" relevant recommendations.
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it → say → recommendations
Thirlwall said the hospital's former chief executive Tony Chambers behaved in a "dictatorial manner" and had "intended" to obstruct a police investigation into deaths on the ward.
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executive → say → ward
Chambers, along with director of nursing and head of safeguarding Alison Kelly and medical director Ian Harvey, "dismissed the idea that Letby was deliberately harming babies", Thirlwall added.
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Thirlwall → dismiss → babies
But whether these managers believed Letby was harming babies or not was "irrelevant", Thirlwall said, adding that action should have been taken as soon as concerns were raised.
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concerns → believe → babies
In a joint statement, Chambers, Kelly and Harvey along with the hospital's former HR director Sue Hodkinson said: "We are carefully reviewing the Thirlwall report and its recommendations.
"
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We → say → report
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.
"
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us → give → time
Our thoughts remain with the families affected by the tragic events that took place at the Countess of Chester Hospital."
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that → remain → Hospital
The inquiry also condemned wider NHS culture, finding evidence of "toxic negativity" that discouraged whistleblowers.
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that → condemn → whistleblowers
The chair of the British Medical Association said on Tuesday that whistleblowers in the NHS "deserve strong protections, and the inquiry makes it clear that these doctors did not get them".
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doctors → say → them
Regulator the Care Quality Commission (CQC) was also criticised, with the report saying it did not show enough curiosity to look beyond what it was being told by the Countess of Chester Hospital.
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it → criticise → Hospital
Responding to the report, the CQC's chief inspector of hospitals said "crucial information" was not shared by the Countess of Chester, but that the commission as a regulator did not take a "sufficiently investigative and inquiring" approach.
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commission → respond → approach
Dr Tony Onon said the regulator had since changed its approach to assessments.
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regulator → say → assessments
Health Secretary Yvette Cooper said she was "profoundly sorry" on behalf of the government for the failures set out in the report.
She said she had asked officials to "urgently develop plans" for cot-cams in neonatal units, and that the government would consider Thirlwall's other recommendations in full.
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government → say → recommendations
Cooper also said she expected NHS leaders across the country to uphold their safeguarding responsibilities.
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leaders → say → responsibilities
She plans to meet Thirlwall, who made 17 recommendations including restricting access to insulin, later this week to discuss the inquiry in more detail.
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who → plan → detail
The consultant paediatrician who had tried to raise his concerns about Letby to hospital management said he accepted the police should have been contacted sooner.
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police → try → management
Dr John Gibbs was working at the Countess of Chester Hospital throughout the period in 2015 to 2016 when Letby carried out her crimes.
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Letby → work → crimes
"I wish we consultants had been brave enough to follow our suspicions and escalate things to the police earlier," he said.
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he → wish → police
"When I say, 'we consultants', I am responsible as well and if my other consultant colleagues didn't go to the police, I should have."
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I → say → police
He also spoke about the failure of consultants to spot the significance of blood test results that suggested a baby had been poisoned with insulin in August 2015.
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baby → speak → August
He described this as "a collective team failure".
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He → describe → failure
He said: "Others of us were on call and covering the neonatal unit over the next week or two before the baby moved out of the unit.
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baby → say → unit
We all had the opportunity to review the notes.
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We → have → notes
"As I admitted when I appeared before the inquiry to give evidence, I feel we failed the babies and I apologise to the families for that.
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I → admit → that
…and 10 more, not listed.
The Aporia
