Dr Tom Dolphin, chairman of the British Medical Association (BMA), said major reforms to NHS safeguarding and culture are needed in the wake of the Thirlwall Inquiry.

He said: “The events at Countess of Chester hospital a decade ago were some of the most appalling we’ve had to face in recent NHS history.

“This tragedy stems from systemic failure and major reforms to NHS culture and safeguarding are now required to make the NHS safer for all in future.”

He said the report showed “the hospital’s management was simply not up to the task of keeping patients safe”.

He added: “After multiple senior doctors raised concerns, they were palmed off and told to stop causing a fuss. This is sadly not unusual in the NHS.

“We have represented many whistleblowers who have been silenced by management for raising safety concerns and who have suffered career-ending consequences.”

Here is more of Tomkinson’s statement:

We firmly believe that the changes we have made, as set out in our evidence to the inquiry, have created a safer environment for our patients and staff. We acknowledge, however, that there is more to be done.

We will now carefully consider the entire content of the Thirlwall report and its recommendations, working with NHS colleagues to embed the learning locally and across the wider NHS.

Our priority is to ensure that we address the Thirlwall report’s recommendations as swiftly as possible, whether through ensuring that actions we have already taken are sustained or by taking further action where needed.

‘We are a different organisation today,’ Countess of Chester Hospital Trust says in wake of damning inquiry

Cooper also said that it is the government’s “intention” to publish a full response to the Thirlwall Inquiry within six months.

Her answer came in response to shadow health secretary Damian Hinds, who described the report as “thorough and devastating”.

He also raised concerns that the system to speak up in the NHS is “uneven” and the Health Bill will abolish the council of governors at NHS trusts and NHS England, leaving whistleblowers few places to turn. Cooper said she plans to review the details of the current system investigating patient safety concerns.

‘This must be a turning point for the NHS,’ health secretary says

Poorly-performing NHS managers to be removed under new barring system, Cooper says

In line with one of the recommendations in the report, the health secretary, Yvette Cooper, said all NHS trusts are signed up to roll out the national bereavement care pathway in 2027, which is meant to ensure high quality and consistent bereavement care throughout the UK, ending the current postcode lottery of provision.

“The report recommends the national bereavement care pathway for neonatal death should be rolled out in 2027 – I agree and can confirm that all trusts are signed up to implement it,” Cooper told the House of Commons.

“I will ensure that it is repeated in all versions of the NHS planning framework while I am the secretary of state.”

Yvette Cooper says plans for cot cams in neonatal units to be ‘urgently’ developed

Cooper says she is ‘profoundly sorry’ for failures set out in report

Ciarán Devane, chief executive of the NHS Alliance, said health leaders across the NHS “will share in the widespread sense of dismay and deep sorrow over the events that unfolded at the Countess of Chester hospital, and the determination to improve safety and accountability in the NHS”.

He added:

They will recognise the inquiry’s strong words 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.

They will welcome the call to strengthen managerial accountability while also implementing better training and support for managers.

We look forward to working with the government as it aims to develop a regulatory system for managers that is effective, equitable and fair, and that is fit for purpose for its intended aims.

Tamlin Bolton, from Irwin Mitchell who represents seven children harmed by Lucy Letby, said: “Lady Thirlwall’s report paints a damning picture of what happens when concerns over patient safety are not listened to and acted on.

“In her own words, a dispiriting and at times shocking account of multiple and repeated failings by organisation and individuals.”

She said there had been direct and frank criticism of all those at senior management level and a description of a chief executive officer “with an intention throughout to stall or obstruct a police investigation”.

She said:

The families recognise that no system can guarantee that deliberate criminal acts will never occur. But when concerns are raised about patient safety, they must be listened to, investigated properly and acted on without delay.

The report today and the criticisms and failings highlighted in it cannot be the end of the matter. The families deserve more than expressions of regret and promises of change.

She said translating the inquiry’s recommendations into “meaningful and lasting change” would honour the children at the centre of the inquiry.

In a joint statement, Sue Hodkinson, Alison Kelly, Ian Harvey and Tony Chambers, the former senior managers at the Countess of Chester Hospital, said: “We are carefully reviewing the Thirlwall report and its recommendations.

“Given that there are a number of investigations under way, and that the work of the Criminal Cases Review Commission has not yet completed, it would be inappropriate for us to offer any further comment at this time.

“Our thoughts remain with the families affected by the tragic events that took place at the Countess of Chester Hospital.”

Dr Toli Onon, who joined the CQC as chief inspector of hospitals last year, said it was sorry for shortfalls in the evidence it could present to the inquiry.

She said:

We are truly sorry for the fact that there were significant shortfalls in CQC’s document management that impacted the evidence we were able to provide to the inquiry.

An independent external review of our information and records management practices has since been undertaken, and learning from that review is being used to improve CQC’s information management practices and document management systems.

The Thirlwall report makes very clear the need to focus on our core purpose and develop teams that work to achieve that purpose.

We are absolutely committed to improving how we work with others to keep people safe and improve care, how we use information to assess quality, identify risk and take appropriate action, and how we give people assurance about the services they rely on.

We will ensure the learning from this report is embedded in the turnaround process CQC is currently engaged in. We are committed to working with the Department of Health and Social Care and wider system partners to play our part in taking forward the recommendations set out by Lady Justice Thirlwall and her team.

The Care Quality Commission (CQC), which is in charge of inspecting hospitals in England, has admitted some of its inquiries and record-keeping fell short when it came to the Countess of Chester Hospital and the Thirlwall Inquiry.

Dr Toli Onon, CQC’s chief inspector of hospitals, said in a statement:

My deepest sympathies go out to the families who continue to suffer as a result of these horrifying crimes. Everyone who has a role in delivering, leading or regulating healthcare services must actively consider the findings of this report to help prevent another situation where premeditated harm goes undetected.

Our focus now must be on what additional safeguards need to be put in place to ensure that patients are better protected from this kind of harm. Our 2016 inspection of Countess of Chester Hospital did not identify an increase in neonatal mortality. Crucial information was not shared by the hospital – however, what is also very clear is that we as the regulator, did not take an approach which was sufficiently investigative and inquiring.

We have learnt from this and our assessment approach has been significantly strengthened since that point in time.

She added:

We now employ a more probing and evidence-led assessment model, with greater emphasis on clinical expertise. We have also made changes to our assessment approach to improve oversight of neonatal services.

Neonatal care is now inspected as a standalone service aligned to maternity, with relevant neonatal data presented to inspectors separately from data for other services – ensuring the whole team has clear and direct access to all intelligence as part of their assessment.

We have added to the range of mortality data sets that we review and are in discussion with NHS England about accessing additional data they hold, to allow more active tracking of mortality.