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Thirlwall report orders board-level monitoring after infant deaths

By Drooid · Sep 15, 2026, 2:36 PM UTC · How we work

Summary

Justice Thirlwall Exposes Failures

Lady Justice Kathryn Thirlwall published a report exposing management and safeguarding failures at Countess of Chester Hospital.
The report found the hospital’s safeguarding policy omitted any mention of deliberate staff harm.
The inquiry identified ignored high insulin results in August 2015 that could have prevented infant deaths.
The report mandates NHS trusts to monitor child and baby deaths at board level by March 31 2027.

Summary

Hospital Managers Arrested

Three senior hospital managers were arrested on suspicion of gross negligence manslaughter, with one also charged with perverting justice.
The public inquiry has cost taxpayers more than £18 million, about $24 million.
The Criminal Cases Review Commission, chaired by Dame Vera Baird, is reviewing Letby’s case after 30 reports.
Lady Justice Thirlwall refused a request by senior executives and Letby’s lawyers to pause the inquiry.

History

Historical Context

The 2008 Healthcare Commission alert over high emergency deaths at Stafford Hospital triggered the Francis public inquiry, which published its final report on 6 February 2013 with 290 recommendations and warned against citing a precise excess-death figure. That inquiry reshaped NHS accountability, and today Lady Justice Kathryn Thirlwall heads a public inquiry into Countess of Chester Hospital, where three senior managers face gross-negligence manslaughter charges.

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Justice Thirlwall Exposes Failures

Lady Justice Kathryn Thirlwall published a report exposing management and safeguarding failures at Countess of Chester Hospital.
The report found the hospital’s safeguarding policy omitted any mention of deliberate staff harm.
The inquiry identified ignored high insulin results in August 2015 that could have prevented infant deaths.
The report mandates NHS trusts to monitor child and baby deaths at board level by March 31 2027.

1 / 3