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.

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.

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

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.

The inquiry said NHS managers have become pre-occupied with avoiding blame, leading to an "over-focus on process and reputation management".

Letby is serving 15 whole-life prison terms for murdering seven babies and attempting to murder seven more. She was convicted in 2023 and has twice been denied permission to appeal against her convictions

This weakness means raising the alarm becomes difficult - a concern that has been repeated again and again in inquiries into other scandals.

But in a number of places the initiative has become a "box ticking" exercise

This view is supported by the most recent NHS staff survey , externalwhich showed a declining confidence in speaking out.

There is, the Thirlwall inquiry said, a consistent inability within the NHS to deal with poor performance.

Countess of Chester chief executive Tony Chambers referred to it as "the donkey sanctuary".

While there are many excellent managers in the NHS, profound change is needed in the way the NHS deals with those who fail, the inquiry added.