Long-awaited Thrilwall inquiry finds three babies may have survived if hospital had acted over concerns raised
The judge said that her report, which has been laid out to parliament, describes “dysfunctional management and governance, a gulf between hospital leadership and clinicians and failure to understand the fundamentals of safeguarding”.
Speaking at Liverpool Town Hall just after her report was published, she added that:
There was also complete failure at all levels to invoke safeguarding procedures at any point.
Looking for clinical or other explanations for deaths and collapses was not wrong, but once there was suspicion that Letby may be causing harm deliberately safeguarding steps should have been taken.
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