Letby failings go beyond one hospital - the whole system has been found lacking

The public inquiry into the Lucy Letby case may have reserved the strongest criticism for the Countess of Chester Hospital and its management, but there are big questions for the wider NHS to answer too.

The Thirlwall inquiry's final report said there was a "complete failure" to protect babies on the neonatal unit where Letby murdered seven and attempted to murder seven more.

But a third of the report was given over to the wider role played by the health system in England - and make no mistake, it was found lacking.

Across more than 200 pages, inquiry chair Lady Justice Thirlwall set out how the culture of the health system created the conditions that enable poor care - or in this case criminality - to go unchecked for so long.

The failures encompass everything from regulation and employment practices to the way the NHS and government struggle to learn the lessons of the past.

They have prompted Health Secretary Yvette Cooper to say she "will not hesitate" to hold the system to account at every level.

She has promised to set up a hub to track the progress on implementing the inquiry's recommendations and pointed to the creation of a new maternity and neonatal commissioner post as a sign of her commitment to improving standards.

"This must be a turning point for the NHS," she told the House of Commons when responding to the publication of the report. So what needs to change?

The inquiry said NHS managers have become pre-occupied with avoiding blame, leading to an "over-focus on process and reputation management".

One witness described this as "blame engineering", with the inquiry concluding this was a key characteristic in the way Countess of Chester bosses approached the Letby case with the report describing it at one point as an "exercise in spin".

This approach to management means raising the alarm becomes difficult - a concern that has been repeated again and again in inquiries into other scandals.

There have been plenty of initiatives to address this over the years. In the last decade, this has taken the form of the Freedom to Speak Up programme with each NHS organisation having a "guardian" whose job is it to support staff who want to issue a concern.

But in a number of places the initiative has become a "box ticking" exercise

The result? A "toxic negativity" persists around whistleblowing with staff discouraged from speaking out, the inquiry said.

This view is supported by the NHS staff survey which showed a declining confidence in speaking out.

There is, the Thirlwall inquiry said, a consistent inability within the NHS to deal with poor performance.

Failing managers will be moved, often with the active assistance of NHS England, in a process referred to as rehabilitation, the inquiry heard.

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

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

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

The government wants to bring in a barring service, but the inquiry warned this will be undermined if the system continues to turn a blind eye like it does.

Regulation has also been found lacking. The Care Quality Commission (CQC) inspected the Countess of Chester in February 2016 - Letby carried on attacking babies until June of that year.

Key information was withheld from inspectors, but the regulator was criticised for not showing enough curiosity to look beyond what they were being told.

Only a year before, the CQC had been warned by another inquiry into baby deaths at Morecambe Bay NHS Trust that it needed to take a tougher approach.

Weaknesses have persisted since, the Thirwall inquiry said. An independent review in 2024 warned the ability of the CQC to spot poor performance was by that point deteriorating.

The CQC has released a statement acknowledging it was not investigative or inquiring enough in 2016, but said it had since strengthened its approach.

Meanwhile, the Nursing and Midwifey Council, which regulates nurses, was also told it should have been more curious - it renewed Letby's registration at a time when she was not permitted to work on a ward and a police investigation was taking place.

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

There has been countless inquiries dating back 30 years, with thousands of recommendations made.

But the Thirwall inquiry said most of these have not been implemented - and, when they have, it has taken too long or progress has not been tracked.

It blamed, among other things, a lack of political will and disruption caused by repeated structural reorganisations.

This had a potentially significant impact in the Letby case, the inquiry suggested. It cited the medical examiner system, whereby an independent doctor looks into deaths that are not reviewed by a coroner so that the cause of death is not down to the doctor involved in the patients care 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 Sir 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.