A public inquiry into the Countess of Chester Hospital found that the deaths of some babies could have been prevented if safeguarding practices had been followed after concerns were raised by staff about former neonatal nurse, Lucy Letby. It also found serious failures in the hospital’s management and oversight.

The Thirlwall inquiry investigated what went wrong with the care of infants in the hospital’s neonatal unit between 2015 and 2018. This included the period of time that Lucy Letby – who has been convicted of seven counts of murder and seven counts of attempted murder – was employed by the hospital.

The inquiry found that senior managers were slow to act on unusual patterns of deaths in the neonatal unit. Relationships between managers and healthcare professionals were often poor. Lady Justice Thirlwall, a judge of the court of appeal who conducted the inquiry, also found the hospital’s leadership appeared at times to be more concerned with preserving the organisation’s reputation than calling in police or regulators.

Read more: Lucy Letby: child murder case highlights need to regulate managers and improve whistleblowing procedures

Thirlwall’s report made 17 recommendations for improving care and assuring the safety of babies and children in all NHS hospitals.

Recommendations, such as installing live-streaming baby monitors in all cots and incubators across NHS neonatal units and improving........

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