Letby failings go beyond one hospital – the whole NHS system has been found lacking

The public inquiry into the Lucy Letby case may have reserved the strongest criticism for the Countess of Chester Hospital and its management, but there are big questions for the wider NHS to answer too.

The Thirlwall inquiry’s final report said there was a “complete failure” to protect babies on the neonatal unit where Letby murdered seven and attempted to murder seven more.

But a third of the report was given over to the wider role played by the health system in England – and make no mistake, it was found lacking.

Across more than 200 pages, inquiry chair Lady Justice Thirlwall set out how the culture of the health system created the conditions that enable poor care – or in this case criminality – to go unchecked for so long.

The failures encompass everything from regulation and employment practices to the way the NHS and government struggle to learn the lessons of the past.

They have prompted Health Secretary Yvette Cooper to say she “will not hesitate” to hold the system to account at every level.

She has promised to set up a hub to track the progress on implementing the inquiry’s recommendations and pointed to the creation of a new maternity and neonatal commissioner post as a sign of her commitment to improving standards.

“This must be a turning point for the NHS,” she told the House of Commons when responding to the publication of the report. So what needs to change?