Report of the public inquiry into events at the Countess of Chester Hospital, 2015 to 2018

Findings

1. Finding 1

   Clinicians raised concerns about a pattern of deaths and collapses. Action to protect babies was delayed, and the doctors who spoke up faced detriment.

   Children and safeguardingLeadership and boardsSpeaking up

2. Finding 2

   Reputation, grievance process and a reluctance to suspect a member of staff took priority over safeguarding.

   Children and safeguardingCulture and conduct

3. Finding 3

   A long list of earlier inquiry recommendations had not stopped the same failures of oversight, data and candour.

   Learning from harmRegulation and oversight

1. 1Awaiting responseNHS England

   Fit in-cot cameras in every neonatal unit, with ring-fenced national funding and a roadmap by March 2027.

   Children and safeguardingDigital and informationMaternity and neonatal care
2. 2Awaiting responseNHS trusts

   Restrict and record access to insulin, and make national guidance on investigating hypoglycaemia mandatory.

   Children and safeguardingMedicines and devices
3. 3Awaiting responseNHS trusts

   Implement the National Bereavement Care Pathway for neonatal death in every trust by August 2027.

   Bereavement care
4. 4Awaiting responseNHS trusts

   Train staff and boards on suspected deliberate harm, and write the duty to follow that guidance into contracts, including bank and agency staff.

   Children and safeguardingTraining and competence
5. 5Awaiting responseNHS England

   Set a dated route to interoperable hospital systems so neonatal information is entered once and can be watched continuously.

   Data and early warningDigital and information
6. 6Awaiting responseHospital trusts

   Make boards monitor every child and baby death, with a fixed route to escalate a worrying trend.

   Data and early warningLeadership and boards
7. 7Awaiting responseHospital trusts

   Name a lead in each neonatal unit for regular mortality data, reporting to the board.

   Data and early warningMaternity and neonatal care
8. 8Awaiting responseNHS England and DHSC

   Apply sudden-unexpected-death procedures to babies who have never left hospital, and shorten the paperwork.

   Children and safeguardingLearning from harm
9. 9Awaiting responseNHS England

   Issue a one-page protocol for when staff suspect a colleague may be causing deliberate harm. Concerns raised in good faith must be acted on, and moving the person can be a neutral step to protect patients.

   Children and safeguardingCulture and conductSpeaking up
10. 10Awaiting responseDHSC

    Create a panel of independent clinical experts who can be sent quickly when harm by an individual is suspected.

    Learning from harmRegulation and oversight
11. 11Awaiting responseNational Medical Examiner and DHSC

    Give medical examiners a clear neonatal checklist, and review whether their funding is adequate in 2027.

    Learning from harmRegulation and oversight
12. 12Awaiting responseDHSC and NHS England

    Expand paediatric and perinatal pathology training to the level the Royal College says is required, by 2033.

    Children and safeguardingSafe staffing
13. 13Awaiting responseDHSC and NHS England

    Bar unfit managers from September 2027, review that scheme in 2030, and aim for full statutory regulation by 2032. Senior moves should not be used to hide conduct or capability problems.

    Accountability of managersRegulation and oversight
14. 14Awaiting responseDHSC and NHS England

    Place an individual duty of candour on managers, and amend the management code so that patient safety is the first duty.

    Accountability of managersCandour
15. 15Awaiting responseCQC

    Inspect hospital departments without notice, with practising specialists on the team, and test whether patients are safe rather than whether a policy exists.

    Regulation and oversight
16. 16Awaiting responseParliament

    Have the Health and Social Care Committee examine CQC's performance regularly.

    Regulation and oversight
17. 17Awaiting responseGovernment

    Move National Guardian functions to the Parliamentary and Health Service Ombudsman, with power to look at how whistleblowing was handled.

    Speaking up
18. 18Awaiting responseGovernment and the National Audit Office

    Ask the National Audit Office to audit whether statutory inquiry recommendations are implemented, starting by September 2027.

    Learning from harmRegulation and oversight