We've been hearing more reaction this morning after the publication of the final Thirlwall Inquiry report on Tuesday.

The report found the deaths and near-deaths of some babies who were attacked by nurse Lucy Letby could have been prevented if safeguarding practices had been followed - here's a reminder of its key findings.

It also laid out a series of recommendations to improve safeguarding measures across the NHS, which the government has said it will now look into, including "urgently" developing a plan to set up cameras in cots on neonatal wards.

Dr Tom Dolphin, chair of the British Medical Association (BMA), says he understands why cameras may be a good idea in the circumstances of neonatal care - and called on the government to strike "while the iron is hot" and implement its plans for a regulator for non-clinical NHS managers.

Lib Dem MP and chair of the health select committee Layla Moran says "a sea change" is needed in the way culture is dealt with in the NHS and how it cares for "our must vulnerable children and babies".

As our health correspondent Nick Triggle reports, calls for a change in NHS culture are a recurring theme of public inquiries - and it's a notoriously difficult thing to do.

Tamlin Bolton, a solicitor representing the families of seven of Letby's victims, says on "almost every page" of the report is "another opportunity where action could have been taken" - and the parents she represents hope the inquiry's finding will help "create change"

And finally, Sir Ciaran Devane, the chief executive of the NHS Alliance, says senior leaders in the NHS are keen to make this a "pivotal moment", adding "everybody is absolutely committed to make sure this never happens again".

We're now bringing our live coverage to an end - for more, you can read this story from our special correspondent Judith Moritz, who has interviewed one of the senior doctors who tried to raise concerns about Lucy Letby with hospital managers.

Calls for a change in NHS culture aren't new - and it's notoriously difficult to dopublished at 09:27 BST 16 September

09:27 BST 16 September

Nick Triggle
Health correspondent

There’s lots of talk about the need to change the culture in the NHS – to one where people feel comfortable raising the alarm and concerns are acted on.

I’ve been reporting on the NHS for 20 years and covered countless public inquiries into other NHS scandals and these are recurring themes.

Changing the culture in the NHS is notoriously difficult.

The Thirlwall inquiry has made this clear, pointing out most recommendations made by previous inquiries have not been implemented – or if they have it has taken too long.

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

This had a potentially significant impact in how long it took to raise the alarm about Lucy Letby.

The inquiry 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 investigation into the failings at Mid Staffordshire NHS Trust - but it took until 2024 for it to be introduced.

Former Health Secretary Sir Jeremy Hunt believes it could have prevented a number of deaths at the Countess of Chester if it had been in place sooner.

The chief executive of the NHS Alliance - which represents the health and care system in England, Wales and Northern Ireland - says senior people who were involved in the Lucy Letby case are no longer in positions of authority.

Speaking to BBC Radio 4's Today programme, Sir Ciaran Devane says senior leaders in the NHS are determined to make sure the publication of the Thirlwall Inquiry is seen as a "pivotal moment" in how it looks at child safeguarding, transparency and precautionary principles.

He says Lady Justice Thirlwall was right to say this must be a fundamental principle on which the whole NHS operates, adding that its membership body supports measures to regulate managers.

"Everybody is absolutely committed to make sure this never happens again," he says.

Following the publication of the report yesterday, Health Secretary Yvette Cooper delivered a statement to the Commons - here's a recap of what she said:

• Cooper apologised - on behalf of both the government and the NHS - for the failures set out in the report, adding that "this must be a turning point for the NHS"
• She said she has told officials to "urgently" develop a plan to set up cameras in cots on neonatal wards, in line with the inquiry's recommendations

• Cooper noted that the process of implementing stronger controls on insulin storage, as recommended by Thirlwall, has already begun, but added that these measures should go further - for context, Letby poisoned two infants with insulin
• In response to Thirlwall's observation that numerous recommendations from inquiries into the NHS over the last 30 years haven't being implemented, Cooper said she is setting up a hub to track implementation

Image source, Scala Legal Marketing

A solicitor representing the families of seven of Lucy Letby's victims says the Thirlwall Inquiry report is "pretty difficult reading" for the families she represents.

"Almost on every page is another opportunity where action could have been taken," Tamlin Bolton tells BBC Radio 4's Today programme.

She says the overriding conclusion of the report is that the responsibility for the delay in contacting the police "lies squarely" with the Countess of Chester Hospital executives.

In a statement yesterday afternoon, the head of the NHS trust which runs the hospital said they were "truly sorry for the events that occurred in 2015 and 2016" and "will approach [the report's] recommendations with openness and a firm commitment to build on the progress we have already made".

Bolton says aside from Letby, the parents blame the senior management team of the hospital and the only thing they look towards is that the report will "hopefully create change".

Judith Moritz
Special correspondent, reporting from Liverpool

One of the senior doctors who tried to raise concerns about Lucy Letby with hospital managers has told the BBC the final report in the Thirlwall inquiry makes for "grim reading" and wishes "we had been brave enough to follow suspicions".

Consultant paediatrician Dr John Gibbs worked at the Countess of Chester Hospital throughout the period in 2015 to 2016 when Letby murdered seven babies, and attempted to murder seven more, on the neonatal unit.

He said that he accepted that consultants must bear "collective" responsibility for some of the failings identified in the report, which described "a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital".

"I wish we consultants had been brave enough to follow our suspicions and escalate things to the police earlier," Gibbs told the BBC.

"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."

• You can read more about this interview in our news story.

More now from British Medical Association (BMA) chair Dr Tom Dolphin.

He calls on the health secretary to implement a regulator for non-medical NHS managers "as soon as possible".

Speaking to BBC Breakfast, Dolphin says he is anxious about changes to the NHS not coming before the end of this Parliament, adding that regulating non-medical managers was a 2024 manifesto commitment from Labour.

In June last year the government released the outcome of its consultation on the proposals to regulate NHS managers, and said it intended "to lay the regulations within this Parliament".

Dolphin says the timeframe of the Thirlwall Inquiry further extends this deadline into the next Parliament - but he believes: "While the iron is hot, we must strike."

Back to this morning's guests on BBC outlets - we're now hearing from Dr Tom Dolphin, chair of the British Medical Association (BMA).

On Health Secretary Yvette Cooper's announcement that the government will "urgently develop" a plan to install live-streaming monitors on cots in neonatal wards in England, Dolphin says colleagues may instinctively feel "a little uncomfortable" about cameras in a clinical setting.

He also says he understands why cameras may be a good idea in the circumstances of neonatal care: "I think things that we can do that make parents have more confidence that their babies are being looked after when they're not there are going to be a good thing."

Here's a reminder of some of the key findings from the Thirlwall Inquiry:

• The deaths and near-deaths of some babies who were attacked by nurse Lucy Letby could have been prevented if safeguarding practices had been followed
• Inquiry chair Lady Justice Thirlwall said it would never be possible to know for sure how many lives could have been saved, but has found there was a "complete failure to protect babies on the neonatal unit" at the Countess of Chester Hospital
• Thirlwall said "this must never happen again" as she called for a "series of urgent reforms to practices" in neonatal units, including restricting access to insulin and installing live-streaming monitors on cots in neonatal wards in England
• Thirlwall highlighted a "profound failure of management, governance and safeguarding"
• She also described a "dysfunctional management and governance, a gulf between hospital leadership and clinicians and a failure to understand the fundamentals of safeguarding"

For more of the report's findings, read our separate news story.

The chair of the health select committee has said the "horrific circumstances" outlined in the Thirlwall Inquiry feel familiar in the context of wider NHS maternity scandals.

Lib Dem MP Layla Moran points out several factors from the report such as whistleblowers not feeling safe, regulators being “too slow off the mark” and families being kept in the dark, adding: “Unfortunately, this isn’t unique in this case.”

Speaking to BBC Breakfast, she says: “We need a sea change in the way that we deal with culture in the NHS in particular, but especially when we are talking about our must vulnerable children and babies.”

The committee chair says she welcomes Health Secretary Yvette Cooper saying she will make children’s health a priority.

“The voice of children is missing from so much of NHS decision making,” Moran adds.

On Tuesday, an inquiry into the hospital where killer nurse Lucy Letby worked published its findings. Among other things, the report said some deaths at the Countess of Chester Hospital could have been prevented. The inquiry's chair Lady Justice Thirlwall also said there was a "complete failure to protect babies" at the hospital and that safeguarding practices weren't followed.

This morning, various experts are speaking to BBC outlets, including Lib Dem MP and chair of the health select committee Layla Moran and Tamlin Bolton, a solicitor representing seven of the victims' families. We'll bring you key lines from their interviews in this page.

As a reminder, Letby is serving 15 whole-life prison terms for murdering seven babies and attempting to murder seven more. She was convicted in 2023 and has twice been denied permission to appeal against her convictions.

Adam Goldsmith
Live reporter

The government says it will look at a series of recommendations, including plans for live-streaming monitors on cots in neonatal wards, after the Thirlwall Inquiry found some baby deaths at the Countess of Chester Hospital could have been prevented.

Former nurse Lucy Letby is serving 15 whole-life prison terms for murdering seven babies and attempting to murder seven more at the hospital between 2015-16. She has twice been denied permission to appeal against her 2023 conviction.

Lady Justice Thirlwall said in her report it would never be possible to say for certain exactly how many lives could have been saved, but said there was a “complete failure to protect babies on the neonatal unit”.

The hospital has apologised and stressed it is a "different organisation today" with better governance and safety processes.

For the NHS, today must be a turning point, Health Secretary Yvette Cooper told the Commons.

Our earlier post describes changes including "urgently" developing plans for cot cameras and a new NHS hub responsible for tracking how inquiry advice is implemented.

Ultimately, a lawyer for several of the babies' families said, today's report "paints a damning picture of what happens when concerns over patient safety are not listened to or acted on".

While Lucy Letby might be the only person criminally liable for the babies' deaths, Our reporter in Liverpool writes, the Thirlwall report expands the footprint of blame to include managers and the health care service more widely.

"Deaths of babies should never again go unnoticed by the board of a hospital," Thirlwall said - you can read a summary of her recommendations in an earlier post.

• We're closing our live coverage now, but you can read more on this story in our news article here

Image source, PA Media

Lady Justice Thirlwall said the behaviour of hospital bosses was "high-handed, contrary to all safeguarding principles, and foolhardy" in her inquiry report.

She added that they ignored patient safety and the need to protect whistleblowers through ignoring "very serious concerns" from colleagues about Lucy Letby, alongside several remarks on specific executives:

Medical director Ian Harvey

• Based on evidence from his successor, Harvey "sought to control the narrative" and presented the case as he saw it to others including the board of directors, NHS England and to some extent, the coroner and police
• Thirlwall said Harvey made sure that only documents that supported his case were seen, if necessary writing them himself

Director of nursing and safeguarding lead Alison Kelly

• Kelly, alongside Harvey, also "ignored deteriorating relationships" between staff members following concerns being raised
• Thirlwall said Kelly, as head of safeguarding, knew she had to act when there was a suspicion a baby had been harmed and others may be at risk, but she "did not do so"

Chief executive Tony Chambers

• A consultant described Chambers as "dictatorial" following a meeting in January 2017
• He also said Chambers had said there was "a need to draw a line under the ‘Lucy issue'"
• The inquiry report said Chambers denied "seeking to stall or obstruct a police investigation" but that was "precisely what he had done"

The three executives, as part of a joint statement, said that they are "carefully reviewing" the report and its recommendations, adding their thoughts remain with the families affected by the tragic events.

All three no longer work at the hospital.

Michael Buchanan
Social affairs correspondent

The NHS was warned about the need to be aware of criminal behaviour by nurses as far back as 1994.

Following the conviction of nurse Beverley Allitt for the murder of three infants and a child at a hospital in Lincolnshire in 1991, a review was ordered.

The Clothier Report said the “mainlesson from our inquiry and our principal recommendation is that the Grantham disaster should serve to heighten awareness in all those caring for children of the possibility of malevolent intervention as a cause of unexplained clinical events".

The chief executive of the NHS at the time, who vowed to take on the recommendations of the report, was Sir Duncan Nichol; at the time of the Letby murders he was chairman of the Countess of Chester Hospital, where she was a nurse.

He spoke at the Thirlwall Inquiry where he said that senior consultants were not invited to a meeting where Letby's future at the hospital was discussed.

Image source, House of Commons

• Health Secretary Yvette Cooper says she has asked officials to "urgently" develop a plan to install cameras in cots on neonatal wards, adding this must be a "turning point" for the NHS
• Richard Scorer, a lawyer acting for three victims' families, says the challenge now is to ensure recommendations are implemented "without delay"
• Tamlin Bolton, a solicitor representing seven of the victims' families, says the lessons learned must be translated into "meaningful and lasting change"
• Lucy Letby's barrister Mark McDonald says Letby is "innocent" which he says "has inevitably affected the report as a whole"
• The NHS trust which runs the Countess of Chester Hospital says it recognises the "enduring impact" on the victims' families and understands "there is more to be done", adding its priority is to address the recommendations as "swiftly as possible"

• Cheshire Constabulary says it is carefully reviewing the report and will "fully consider" any relevant recommendations in light of its ongoing investigation

As a reminder, the force launched an investigation into corporate manslaughter and gross negligence manslaughter at the Countess of Chester Hospital after Letby's conviction in 2023, which remains ongoing.

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 say 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.