Ministers vow sweeping NHS changes after ‘devastating’ report on Lucy Letby hospital | Lucy Letby

Ministers have promised sweeping changes to the NHS after a “devastating” official review concluded that three babies might have survived if hospital bosses and doctors had acted on concerns about the nurse Lucy Letby.

A public inquiry found a “complete failure” to protect babies on the neonatal unit at the Countess of Chester hospital in north-west England.

In a series of findings, the inquiry chair, Lady Justice Thirlwall, said two newborn twins would not have died and five others would not have been harmed if Letby had been removed from the unit sooner.

Thirlwall said a third baby who died, a two-month-old girl, and two others who suffered unexplained collapses might have been protected if a doctor had detected an earlier insulin poisoning on the unit. One of those infants, now aged 11, suffered a lifelong brain injury and needs 24-hour care.

Yvette Cooper, the health secretary, said she was “profoundly sorry” for the “devastating” failures revealed in the report, telling MPs: “This must be a turning point for the NHS.” She said she had asked officials to urgently take forward plans for “cot cam” monitors for neonatal units in line with Thirlwall’s recommendation.

However, Letby’s barrister, Mark McDonald, told the Guardian the government had “moved with too much haste” and acted before the outcome of her challenge to her convictions was known.

Letby, 36, is serving 15 whole-life prison terms after being convicted of the murder of seven babies and attempted murder of seven other newborns at the hospital in the year to June 2016.

The former neonatal nurse is fighting to overturn her convictions, which have been described by the senior Conservative MP David Davis as a “clear miscarriage of justice”.

The Criminal Cases Review Commission (CCRC), which investigates potential miscarriages of justice, is reviewing a dossier of evidence submitted by experts on her behalf before deciding whether to refer the case back to the court of appeal, which has twice rejected her legal challenges.

Delivering her report at Liverpool town hall on Tuesday, where families of some of the babies had gathered, Thirlwall said: “My report describes dysfunctional management and governance; a gulf between hospital leadership and clinicians; and failure to understand the fundamentals of safeguarding.

“There was a complete failure to protect babies on the neonatal unit at the Countess of Chester hospital. This was because no one seems to have understood that safeguarding action is required when a member of staff is suspected of causing deliberate harm and does not require colleagues to be sure of guilt.”

Families of the babies who died or were injured said the report painted a “damning picture of what happens when concerns over patient safety are not listened to and acted on”.

Tamlin Bolton, a solicitor at Irwin Mitchell representing seven of the families, urged ministers and the NHS to act on the report’s recommendations, saying: “It cannot be the end of the matter.”

Richard Scorer, of the law firm Slater and Gordon, which represents three of the families, said: “Far too often public inquiry recommendations are left to gather dust. This cannot be allowed to happen again.”

In her 822-page report, Thirlwall said it was “inexcusable” that successive governments had failed to act on reforms proposed by other public inquiries into NHS scandals stretching back 30 years.

Thirlwall is said to believe that “cot cams” – allowing parents to monitor their newborn around-the-clock – could have prevented all seven of the deaths as medics would know they were being monitored.

Samantha Dixon, the Labour MP for Chester North, whose constituency includes the hospital, said the inquiry revealed a “truly appalling state of affairs” that needed “the firmest response possible from government”.

Ministers are working on the urgent introduction of other CCTV in hospital neonatal units as well as cot cams, in line with Thirlwall’s recommendation, as well as stricter rules on the storage of insulin.

Hospital executives who are found to have failed in their responsibilities will be prevented from working again in the NHS under new regulation to stop managers being transferred to another part of the country.

And they will roll out a single tracker to monitor the delivery of recommendations made by inquiries into maternity and neonatal scandals.

McDonald, Letby’s barrister, said: “The government has moved with too much haste. They have made the same mistake as Thirlwall not to pause and wait for the new evidence to be considered.”

However, others said the inquiry’s findings and recommendations must be taken seriously irrespective of Letby’s legal challenge.

Dr Tom Dolphin, chair of the British Medical Association (BMA), said it stemmed from “system reform” within the NHS and that it required “major reforms” to the culture of the health service.

Leaders of NHS trusts and other bodies said the inquiry had shone a light on the “upheaval caused by successive reorganisations, the complex regulatory landscape, staff shortages, unacceptable ‘revolving door’ appointments and the inadequacies of under-funded NHS IT systems”.

Letby was first linked to baby deaths in June 2015. In less than two weeks that month, three newborns died in unexplained circumstances within two weeks – the number usually expected on the neonatal unit in a year.

Senior doctors became concerned about Letby’s connection to the unusual rise in deaths and serious incidents over the following months and raised their fears with executives. However, the inquiry found that senior nurses effectively dismissed the concerns about Letby and that there was a “prolonged delay” in calling the police.

Rather than being believed, Thirlwall said, clinicians were themselves made the subject of investigation in a “deplorable” grievance process brought by Letby when she was finally removed from the neonatal unit in July 2016.

Parents were “kept in the dark” for years about what happened to their babies and the concerns they may have been deliberately harmed, the inquiry found. Thirlwall described their treatment as “reprehensible”.

The inquiry chair accused hospital executives of overseeing “an exercise in spin” by downplaying the rise in deaths to the board of directors. Their failure to contact police before April 2017 – nearly two years after the unexplained increase in deaths – suggested that protecting the hospital’s reputation was “prized more highly” than the doctors’ concerns, she found.

Three hospital executives, who have not been named, were arrested last year on suspicion of gross negligence manslaughter. Cheshire police said its investigation into the former bosses, and a parallel investigation into corporate manslaughter, was ongoing.

Thirlwall, a court of appeal judge, said it was “clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier”. She said the precise number of deaths that might have been prevented would never be known for sure.

However, the inquiry concluded that if Letby had been removed from duties in October 2015 – when senior managers were made aware of the concerns – then the twin boys known as babies O and P would not have died in June 2016 and five further babies would not have suffered harm.

Thirlwall said it was possible that three newborns would not have died and seven others would have been protected if a senior doctor had not “disregarded” an insulin result for a week-old baby boy in August 2015, whom Letby was later convicted of attempting to murder by poisoning him.