Daily Junction.mobi portalHealth · September 17, 2026 · The Conversation · 5 min
The report described the number of ways that management and organisational faults contributed to the tragedies that occurred at the hospital.
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<span><a href="https://theconversation.com/profiles/judith-smith-330064">Judith Smith</a>, <em><a href="https://theconversation.com/institutions/university-of-birmingham-1138">University of Birmingham</a></em></span>
<p>A public inquiry into the Countess of Chester Hospital found that the deaths of some babies could have been prevented if <a href="https://thirlwall.public-inquiry.uk/2026/09/15/inquiry-report-finds-profound-failure-of-management-governance-and-safeguarding/">safeguarding practices</a> had been followed after concerns were raised by staff about former neonatal nurse, Lucy Letby. It also found serious failures in the hospital’s management and oversight.</p>
<p>The <a href="https://thirlwall.public-inquiry.uk/the-report/#Summary-report-on-report-page">Thirlwall inquiry</a> investigated what went wrong with the care of infants in the hospital’s neonatal unit between 2015 and 2018. This included the period of time that <a href="https://theconversation.com/topics/lucy-letby-143770">Lucy Letby</a> – who has been convicted of <a href="https://www.theguardian.com/uk-news/2026/sep/15/lucy-letby-public-inquiry-thirlwall-report">seven counts of murder</a> and seven counts of attempted murder – was employed by the hospital. </p>
<p>The inquiry found that senior managers were slow to act on unusual patterns of deaths in the neonatal unit. Relationships between managers and healthcare professionals were often poor. Lady Justice Thirlwall, a judge of the court of appeal who conducted the inquiry, also found the hospital’s leadership appeared at times to be more concerned with preserving the organisation’s reputation than calling in police or regulators. </p>
<p>Thirlwall’s report made 17 recommendations for improving care and assuring the safety of babies and children in all NHS hospitals.</p>
<p>Recommendations, such as installing live-streaming baby monitors in all cots and incubators across NHS neonatal units and improving the safe storage of insulin, make sense as ways of preventing the kind of avoidable deaths that happened in Chester. </p>
<p>Other recommendations, such as regulating managers, may come across as bureaucratic or obscure. But nothing could be further from the case. </p>
<p>I gave evidence as part of the inquiry. I think Thirlwall’s recommendations to overhaul management of NHS hospitals could – if implemented with the right investment and support – help prevent such tragedies in the future. </p>
<h2>Four key improvements</h2>
<p>There are four ways Thirlwall’s recommendations for NHS management could, if implemented, improve how hospitals are run. </p>
<p>First, every NHS trust needs well-functioning clinical governance, a <a href="https://www.bmj.com/content/317/7150/61">system that actually catches problems with patient care</a>, giving managers, staff and hospital boards a clear picture of safety issues as they arise. Trusts should also take their <a href="https://www.england.nhs.uk/ourwork/part-rel/nqb/about-quality-accounts/">annual quality account</a> – the report on the standard of care they provide – seriously, using it to track improvements and flag what still needs fixing.</p>
<p>Reforming how the <a href="https://www.gov.uk/government/publications/review-of-patient-safety-across-the-health-and-care-landscape">Care Quality Commission</a> inspects hospitals could help too, by pushing local hospitals to have robust systems to spot their own failings and act on them.</p>
<p>Second, Thirlwall repeated calls from earlier inquiries to create more formal regulation of managers. She suggests requiring a code of conduct that is enshrined in an NHS manager’s employment contract that has the care and safety of patients at its heart. </p>
<p>A code of conduct was first introduced in the NHS in 2002 – but its use was <a href="https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-evidence/INQ0101380.pdf">“at best voluntary”</a>. Having such a code could embolden managers to speak out about failings in patient care or poor organisational practice. It might also empower them to seek support if they are unable to meet the standards in the code. </p>
<p>The inquiry also highlighted a revolving door of employment, where senior managers who had performed poorly or who’d had concerns raised about them were able to leave one hospital and get a job at another. Regulating managers, and being able to strike off those who fail patients, would make it harder for poor performers to simply move on to their next job.</p>
<p>But regulation needs to go hand-in-hand with <a href="https://www.kingsfund.org.uk/insight-and-analysis/long-reads/why-management-matters-nhs-10-year-plan">high-quality training and development</a>. This is so managers at all career stages have the necessary skills, updating and support to perform their complex and highly responsible roles.</p>
<p>Third, managers and board members should also be required to be open with patients and families when something goes wrong. This is known as the “duty of candour”. It currently applies to doctors, nurses and other healthcare professionals, who must tell patients and families when a mistake has been made or someone has been harmed, and explain what is being done about it.</p>
<p>There have been examples where leaders have <a href="https://www.bbc.co.uk/news/articles/ce8kkd3jwdzo">refused to give evidence</a> to local inquiries. For senior public servants to do this undermines people’s trust in the NHS and its leaders.</p>
<p>Finally, this is not just about what happens within hospitals. Those leading NHS trusts need to <a href="https://assets.publishing.service.gov.uk/media/5bfd6ec3ed915d1199c8b228/Ron_Kerr_report_-_Empowering_NHS_leaders_to_lead.pdf">feel empowered to speak out</a> about problems faced by their organisation.</p>
<p>Too often, managers and leaders are under pressure to make reports about their hospital and its care <a href="https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry">look better</a> than they really are when patients, families or staff raise concerns.</p>
<p>Studies show that hospital leaders also often <a href="https://assets.kingsfund.org.uk/f/256914/x/6fc230581b/chief_executive_tale_2016.pdf">feel compelled</a> to give such good news to their political masters, while simultaneously being concerned about being upfront to patients, staff and local communities about the problems their trust may face.</p>
<p>This can <a href="https://www.cambridge.org/core/elements/making-culture-change-happen/AB1E89CABE939DAB47C641BFDE56F150">create cultures of fear</a>, cause burnout among managers and, critically, mean that important issues aren’t sufficiently addressed. I argued in my evidence to the Thirlwall inquiry that the duty of candour, along with a code of conduct for managers, needs to apply equally to officials and managers supervising hospitals.</p>
<p>To be an NHS manager is to hold huge responsibility for the care and safety of patients and their families. If Lady Thirlwall’s recommendations about manager regulation and organisational governance are implemented thoughtfully, NHS leaders might feel strengthened in making important decisions that will benefit patients and the communities they serve.<!-- Below is The Conversation's page counter tag. Please DO NOT REMOVE. --><img src="https://counter.theconversation.com/content/292071/count.gif?distributor=republish-lightbox-basic" alt="The Conversation" width="1" height="1" style="border: none !important; box-shadow: none !important; margin: 0 !important; max-height: 1px !important; max-width: 1px !important; min-height: 1px !important; min-width: 1px !important; opacity: 0 !important; outline: none !important; padding: 0 !important" referrerpolicy="no-referrer-when-downgrade" /><!-- End of code. If you don't see any code above, please get new code from the Advanced tab after you click the republish button. The page counter does not collect any personal data. More info: https://theconversation.com/republishing-guidelines --></p>
<p><span><a href="https://theconversation.com/profiles/judith-smith-330064">Judith Smith</a>, Professor of Health Policy and Management, <em><a href="https://theconversation.com/institutions/university-of-birmingham-1138">University of Birmingham</a></em></span></p>
<p>This article is republished from <a href="https://theconversation.com">The Conversation</a> under a Creative Commons license. Read the <a href="https://theconversation.com/lucy-letby-thirlwall-inquiry-lays-bare-the-responsibility-of-nhs-management-heres-what-needs-to-change-for-the-future-292071">original article</a>.</p> </div>