Systemic Failure: What the Thirlwall Inquiry Exposes About NHS Culture The Thirlwall inquiry's findings paint a damning picture of systemic failure at the Countess of Chester Hospital, where serial killer Lucy Letby murdered seven babies and attempted to murder seven others.
This is not an isolated incident but rather a symptom of a broader culture of cover up and blame shifting within the NHS.
Leadership failures are evident throughout the report, with executives repeatedly disregarding their duty of candour to parents, investigators, and regulators.