Report to the Thirlwall Inquiry: addressing Part C of the Terms of Reference

Summary

The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital.

Mary Dixon-Woods, Health Foundation Professor of Healthcare Improvement Studies, Director, THIS Institute Department of Public Health and Primary Care University of Cambridge, has been asked by the Thirlwall Inquiry team to address a number of questions in relation to Part C of the Terms of Reference. It brings together a considerable wealth of evidence, research and history on what is known about patient safety culture and systems.