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It is an 822-page doughnut... weighty around the edges, with a great hole where the central question should be.
Seventeen urgent recommendations. Three years in the making and costing more than £18m.
The Thirlwall Inquiry describes a hospital where warnings were ignored, risks minimised, consultants threatened and managers appeared more frightened of reputational damage than the possibility babies were being harmed.
It is a shocking story of leadership failure.
The Inquiry was established after Lucy Letby had been convicted of murdering seven babies and attempting to murder seven more at the Countess of Chester Hospital.
Its job was to discover how she had been allowed to do it, not… not whether she had.
That distinction has become increasingly important.
Since the convictions, a sustained campaign has questioned the medical evidence, statistics, police investigation, conduct of the trial and ultimately the safety of the verdicts.
An international panel of neonatal specialists concluded there was no medical evidence of deliberate harm, offering natural explanations and failures of clinical care for the deaths and collapses.
The criticism is contested. Her convictions stand. Nothing in Thirlwall overturns them… this was outside the Inquiry’s terms of reference.
Thirlwall was not asked to test that premise.
It was asked to retrofit the hospital’s failures around it.
Its conclusions about how later attacks could have been prevented follow from that premise; they do not independently test them.
Thirlwall is devastating when it follows the evidence at Chester. It's frankly, hopeless when it turns the failures of one board into an indictment of NHS management.
Thirlwall says; the move towards a ‘no blame’ culture, starting in 2000, was a mistake. (Volume III, Chapter 39, “Culture of the NHS”, printed pages 89–91).
That’s really odd. Proper safety practice doesn’t eliminate accountability...
... it distinguishes honest error from negligence, recklessness and deliberate harm, and…
... examines the system that allowed it to happen…
…it’s also at odds with the NHS’s current system-based approach, and, oddly…
… with Thirlwall’s own endorsement of HSSIB’s no-blame investigations.
It recommends regulating all NHS managers, however...
... the senior managers at the centre of events at Chester were clinically qualified and professionally regulated.
Regulation didn’t make a damn of difference.
Thirlwall implies hospital managers control all the resources. No, many are determined nationally.
These sweeping conclusions risk offering another structural answer to what was fundamentally a failure of judgement, curiosity and courage.
Thirlwall concludes that two babies would have survived and five others would have escaped harm had Letby been removed in October 2015. Earlier recognition of an insulin result, it says, 'might have protected three more.'
That answers the safeguarding question... what should managers have done when doctors suspected deliberate harm?
It does not answer the evidential question… was deliberate harm proved correctly in every case?
A murderer can work in a badly managed hospital. Staffing shortages do not explain everything the juries heard; the unusual collapses, insulin results, Letby’s presence and the wider web of circumstantial evidence.
Nevertheless, the report exposes an uncomfortable alternative possibility.
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The neonatal unit was cramped and outdated.
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Nursing numbers were 21% below recommended levels.
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There were shortages of doctors and consultants.
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Consultant-led ward rounds took place only twice a week.
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Paediatrics and neonatology had been reorganised into obscurity, separated from maternity services and effectively disconnected from the Trust board.
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An earlier clinical review placed four cases in a category where the collapse or death was considered explained but might have been prevented with different care.
These are not incidental details. The same hospital failings can support two opposing stories.
One… a serial murderer exploited a poorly governed organisation whose leaders failed to act on repeated warnings.
The other… failures of care contributed to deaths and collapses subsequently interpreted as murder.
Thirlwall could examine only the first.
The report does not prove Letby innocent or the convictions unsafe. Equally, its conclusions cannot be used as fresh, independent confirmation of her guilt.
The Criminal Cases Review Commission must decide whether the new expert evidence and clinical failings documented by Thirlwall materially affect the case.
If there is a real possibility the convictions would not be upheld, they should be referred back to the Court of Appeal, where the medical evidence can be tested under oath and cross-examination.
If this report were a novel, it would have a predetermined ending, an unreliable narrator and a plot-hole at its centre.
By the time Thirlwall reported, she knew her inquiry’s premise was under serious challenge.
The sensible course was to pause until the CCRC and any appeals were concluded.
Instead, she presented conclusions resting on contested convictions and a collection of misunderstandings... as settled fact.
As a result we have a report that we can largely ignore.
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