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Countess of Chester Hospital Inquiry

Volume 737: debated on Monday 4 September 2023

With permission, Mr Speaker, I would like to make a statement on the inquiry into the circumstances surrounding the crimes of Lucy Letby.

On 18 August, as the whole House is aware, Letby was convicted of the murder of seven babies and the attempted murder of six others. She committed these crimes while working as a neonatal nurse at the Countess of Chester Hospital between June 2015 and June 2016. As Mr Justice Goss said as he sentenced her to 14 whole life orders, this was a

“cruel, calculated and cynical campaign of child murder”

and a

“gross breach of the trust all citizens place in those who work in the medical and caring professions.”

I think the whole House will agree it is right that she spends the rest of her life behind bars.

I cannot begin to imagine the hurt and suffering that these families went through, and I know from my conversations with them last week that the trial brought these emotions back to the surface. Concerningly, that was exacerbated by the fact the families discovered new information about events concerning their children during the course of the trial.

Losing a child is the greatest sorrow any parent can experience. I am sure the victims’ families have been in the thoughts and prayers of Members across the House, as they have been in mine. We have a duty to get them the answers they deserve, to hold people to account and to make sure lessons are learned. That is why, on the day of conviction, I ordered an independent inquiry into events at the Countess of Chester Hospital, making it clear that the victims’ families would shape it.

I arranged with police liaison officers to meet the families at the earliest possible opportunity to discuss with them the options for the form the inquiry should take, and it was clear that their wishes are for a statutory inquiry with the power to compel witnesses to give evidence under oath. That is why I am confirming this to the House today.

The inquiry will examine the case’s wider circumstances, including the trust’s response to clinicians who raised the alarm and the conduct of the wider NHS and its regulators. I can confirm to the House that Lady Justice Thirlwall will lead the inquiry. She is one of the country’s most senior judges. She currently sits in the Court of Appeal, and she had many years of experience as a senior judge and a senior barrister before that. Before making this statement, I informed the victims’ families of her appointment, which was made following conversations with the Lord Chief Justice, the Lord Chancellor and the Attorney General.

I have raised with Lady Justice Thirlwall the fact that the families should work with her to shape the terms of reference. We hope to finalise those in the next couple of weeks, so that the inquiry can start the consultation as soon as possible. I have also discussed with Lady Justice Thirlwall the families’ desire for the inquiry to take place in phases, so that it provides answers to vital questions as soon as possible. I will update the House when the terms of reference are agreed and will continue to engage with the families.

Today, I would also like to update the House on actions that have already been taken to improve patient safety and identify warning signs more quickly, as well as action that is already under way to strengthen that further. First, in 2018, NHS England appointed Dr Aidan Fowler as the first national director of patient safety. He worked with the NHS to publish its first patient safety strategy in 2019, creating several national programmes. Those included requiring NHS organisations to employ dedicated patient safety specialists, ensuring that all staff receive robust patient safety training and using data to quickly recognise risks to patient safety. Last summer, to enhance patient safety further, I appointed Dr Henrietta Hughes, a practising GP, as England’s first patient safety commissioner for medicines and medical devices. Dr Hughes brings leaders together to amplify patients’ concerns throughout the health system.

Secondly, in 2019, the NHS began introducing medical examiners across England and Wales to independently scrutinise deaths not investigated by a coroner. Those senior doctors also reach out to bereaved families and find out whether they have any concerns. All acute trusts have appointed medical examiners who now scrutinise hospital deaths and raise any concerns they have with the appropriate authorities.

Thirdly, in 2016, the NHS introduced freedom to speak up guardians, to assist staff who want to speak up about their concerns. More than 900 local guardians now cover every NHS trust. Fourthly, in 2018, Tom Kark KC was commissioned to make recommendations on the fit and proper person test for NHS board members. NHS England incorporated his review findings into the fit and proper person test framework published last month. It introduced additional background checks, the consistent collection of directors’ data and a standardised reference system, thus preventing board members unfit to lead from moving between organisations.

Finally, turning to maternity care, in 2018 NHS England launched the maternity safety support programme to ensure that underperforming trusts receive assistance before serious issues arise. Also since 2018, the Government have funded the national perinatal mortality review tool, which supports trusts and parents to understand why a baby has died and whether any lessons can be learned to save lives in the future. Furthermore, the Government introduced the maternity investigations programme, through the Health Safety Investigation Branch, which investigates maternity safety incidents and provides reports to trusts and families. In 2020, NHS England’s Getting It Right First Time programme was expanded to cover neonatal services. It reviewed England’s neonatal services using detailed data and gave trusts individual improvement plans, which they are working towards. Indeed, Professor Tim Briggs, who leads that programme, has confirmed that all neonatal units have been reviewed by his programme since 2021.

Let me now turn to our forward-facing work. We have already committed to moving medical examiners to a statutory basis and will table secondary legislation on that shortly. It will ensure that deaths not reviewed by a coroner are investigated in all medical settings, in particular extending coverage in primary care, and will enter into force in April.

Secondly, on the Kark review, at the time the NHS actively considered Kark’s recommendation 5 on disbarring senior managers and took the view that introducing the wider changes he recommended in his review mitigated the need to accept that specific recommendation on disbarring. The point was considered further by the Messenger review.

In the light of evidence from Chester and ongoing variation in performance across trusts, I have asked NHS England to work with my Department to revisit this. It will do so alongside the actions recommended by General Sir Gordon Messenger’s review of leadership, on which the Government have already accepted all seven recommendations from the report dated June last year. This will ensure that the right standards, support and training are in place for the public to have confidence that NHS boards have the skills and experience needed to provide safe, quality care.

Thirdly, by January all trusts will have adopted a strengthened freedom to speak up policy. The national model policy will bring consistency to freedom to speak up across organisations providing NHS services, supporting staff to feel more confident to speak up and raise any concerns. I have asked NHS England to review the guidance that permits board members to be freedom to speak up guardians, to ensure that those roles provide independent challenge to boards.

Fourthly, the Getting it Right First Time programme team will launch a centralised and regularly updated dataset to monitor the safety and quality of national neonatal services.

Finally, we are exploring introducing Martha’s rule to the UK. Martha’s rule would be similar to Queensland’s system, called Ryan’s rule. It is a three-step process that allows patients or their families to request a clinical review of their case from a doctor or nurse if their condition is deteriorating or not improving as expected. Ryan’s rule has saved lives in Queensland, and I have asked my Department and the NHS to look into whether similar measures could improve patient safety here in the UK.

Mr Speaker, I want to take the first opportunity on the return of the House to provide an update on the Essex statutory inquiry. In June, I told the House that the inquiry into NHS mental health in-patient facilities across Essex would move forward on a statutory footing. Today, I can announce that Baroness Lampard, who led the Department of Health’s inquiry into the crimes of Jimmy Savile, has agreed to chair the statutory inquiry. I know that Baroness Kate Lampard will wish to engage with Members of the House and the families impacted, and following their input I will update the House on the terms of reference at the earliest opportunity.

The crimes of Lucy Letby were some of the very worst the United Kingdom has witnessed. I know that nothing can come close to righting the wrongs of the past, but I hope that Lady Justice Thirlwall’s inquiry will go at least some way towards giving the victims’ families the answers they deserve. My Department and I are committed to putting in place robust safeguards to protect patient safety and to making sure that the lessons from this horrendous case are fully learned. I commend this statement to the House.

I strongly echo the sentiments of the Secretary of State and thank him for advance sight of his statement. I welcome the appointment of Lady Justice Thirlwall to lead the inquiry into the crimes committed by Lucy Letby, and I strongly welcome his appointment today of Baroness Lampard to lead the statutory review in Essex. I look forward to receiving further updates from the Secretary of State as soon as possible.

Turning to the case of Lucy Letby, there are simply no words to describe the evil of the crimes that she committed. They are impossible to fathom. Although she has now been convicted and sentenced to a whole-life order, the truth is that no punishment could possibly fit the severity of the crimes she committed. With Cheshire police’s investigation having expanded to cover her entire clinical career, we may not yet know the extent of her crimes. What we do know is that her victims should be starting a new school term today. Our thoughts are with the families who have suffered the worst of traumas, whose pain and suffering we could not possibly imagine, and who will never forget the children cruelly taken from them. We hope that the sentencing helped to bring them some closure, even though the cowardly killer dared not face them in court.

I wish to pay tribute to the heroes of this story: the doctors who fought to sound the alarm in the face of hard-headed, stubborn refusal. This murderer should have been stopped months before she was finally suspended. Were it not for the persistent courage of the staff who finally forced the hospital to call in Cheshire police, more babies would have been put at risk. I am sure the whole House will want to join me in recognising Dr Stephen Brearey and Dr Ravi Jayaram, whose bravery has almost certainly saved lives.

Blowing the whistle on wrongdoing is never easy, which is why it should not be taken lightly. Indeed, we can judge the health of an institution by the way that it treats its whistleblowers. The refusal to listen, to approach the unexplained deaths of infants with an open mind and to properly investigate the matter when the evidence appeared to be so clear is simply unforgivable. The insult of ordering concerned medics to write letters of apology to this serial killer demonstrates the total lack of seriousness with which their allegations were treated.

I welcome the fact that the Secretary of State has changed the terms of the inquiry and put it on a statutory footing. There must be no hiding place for those responsible for such serious shortcomings. It is welcome that the inquiry will have the full force of the law behind it, as it seeks to paint the full picture of what went wrong at the Countess of Chester Hospital, and it is right that the wishes of the families affected have been listened to. I welcome the fact that they will be involved in the drawing up of the terms of reference.

I ask the Secretary of State, people right across Government and people who hope to be in government to make sure that, in future, in awful cases such as this, families and victims are consulted at the outset. Can he assure the House that the families will continue to be involved in decisions as the inquiry undertakes its work?

Mr Speaker, no stone can be left unturned in the search for the lessons that must be learned, but it is already clear that there were deep issues with the culture and leadership at the Countess of Chester Hospital. This is not the first time that whistleblowers working in the NHS have been ignored, when listening to their warnings could have saved lives. Despite several reviews, there is no one who thinks that the system of accountability, of professional standards and of regulation of NHS managers and leaders is good enough.

Why were senior leaders at the Countess of Chester Hospital still employed in senior positions in the NHS right up to the point that Lucy Letby was found guilty of murder? The absence of serious regulation means that a revolving door of individuals with a record of poor performance or misconduct can continue to work in the health service. Does the Secretary of State agree that that is simply unacceptable in a public service that takes people’s lives into its hands?

The lack of consistent standards is also hampering efforts to improve the quality of management. I am sure the Secretary of State will agree that good management is absolutely vital for staff wellbeing, clinical outcomes, efficient services and, most of all, patient safety. The case for change has been made previously. Sir Robert Francis, who led the inquiry into the deaths at Mid Staffs, argued in 2017 that NHS managers should be subject to professional regulation. In 2019, the Kark review, commissioned by the Secretary of State, called for a regulator to maintain a register of NHS executives, with

“the power to disbar managers for serious misconduct”.

In 2022, the Messenger review commissioned by the right hon. Member for Bromsgrove (Sajid Javid) recommended a single set of core leadership and management standards for managers, with training and development provided to help them meet these standards. We must act to prevent further tragedies, so I welcome the Secretary of State’s announcement that his Department is reconsidering Kark’s recommendation 5. Labour is calling for the disbarring of senior managers found guilty of serious misconduct, so I can guarantee him our support if he brings that proposal forward.

The Secretary of State should go further. Will he now begin the process of bringing in a regulatory system for NHS management, alongside standards and quality training? Surely we owe it to the families and the staff who were let down by a leadership team at the Countess of Chester Hospital that was simply not fit for purpose.

Finally, I know that I speak for the whole House when I say that the parents of Child A, Child C, Child D, Child E, Child G, Child I, Child O and Child P are constantly in our thoughts, as are the many other families who worry whether their children have also been victims of Lucy Letby. We owe it to them to do what we can to prevent anything like this from ever happening again. As the Government seek to do that, they will have our full support.

I thank the hon. Gentleman for the content of his response and the manner in which he delivered it. I think it underscores the unity of this House in our condemnation of these crimes, and our focus on putting the families at the centre of getting answers to the questions that arise from this case. I join him in paying tribute to those consultants who spoke up to trigger the police investigation and to prevent further harm to babies. I note the further work that the police are doing in this case, and also pay tribute to the police team, which I had the privilege of meeting. They have worked incredibly hard in very difficult circumstances in the course of this investigation.

As the hon. Gentleman said, the families are absolutely central to the approach that we are taking. That is why I felt that it was very important to discuss with them the relative merits of different types of inquiry, but their response was very clear in terms of their preference for a statutory inquiry. I have certainly surfaced to Lady Justice Thirlwall some of the comments from the families in terms of the potential to phase it. Of course, those will be issues for the judge to determine.

On the hon. Gentleman’s concerns around the revolving door, clearly a number of measures have already been taken, but I share his desire to ensure that there is accountability for decisions. As Members will know, I have been vocal about that in previous roles, and it is central to many of the families’ questions on wider regulation within the NHS.

The hon. Gentleman mentioned the importance of good management. I am extremely interested in how, through this review and the steps we can take ahead of it, we give further support to managers within the NHS and to non-exec directors. The Government accepted in full the seven recommendations of the Messenger review. The Kark review was largely accepted. There was the issue of recommendation 5, which is why it is right that we look again at that in the light of the further evidence.

It is clear that a significant amount of work has already gone in. A number of figures, including Aidan Fowler and Henrietta Hughes, have focused on safeguarding patient safety, but in the wake of this case we need to look again at where we can go further, which the statutory inquiry will do with the full weight of the law. I am keen, however, that we also consider what further, quicker measures can be taken. Indeed, I have been in regular contact with NHS England to take that work forward.

I place on record my sympathy to the families, who have conducted themselves with the utmost dignity throughout this process and who remain in my thoughts and prayers as well. I welcome the judge-led statutory inquiry that my right hon. Friend has announced. It is the right thing to do, as are the phases of the inquiry, which prevent stuff from taking too long to move fast. As that work moves forward, and the debate rightly continues to touch on how we regulate managers working in the NHS, and remove them, I ask that Ministers remain alert to any “us and them” thinking between managers and clinicians. Surely any successful hospital trust is one team working together, so that defensive medicine is all but impossible.

I very much agree with the Chair of the Select Committee on the need for a one-team approach, and on looking at how we encourage more clinicians into management roles. We need to be clear-eyed that often some of those in management positions were already regulated, because they were in medical or nursing regulatory positions, but it is important that we consider the right approach to ensure accountability for the families. That is why NHS England will look at this further.

Terrible crimes have been committed in the Countess of Chester Hospital in my constituency—my hospital. I thank the Secretary of State for meeting and listening to the families at the heart of this tragic case and for instituting a statutory inquiry into the circumstances surrounding these crimes. Serious questions about NHS accountability and governance have arisen that the inquiry will need to address. Given that the scope of Cheshire police’s Operation Hummingbird has now broadened, what reassurance can the Secretary of State offer my community about our hospital?

First of all, I pay tribute to the hon. Lady for the work she has done with the families and the staff in response to these terrible events. It is important that we reassure patients who are using the Countess of Chester Hospital now about the measures that have been put in place; that is why I wanted to bring to the House’s attention House the steps that have already been taken.

However, it was also striking in my discussions with family members that they were at pains to point out that some of the other staff they had been treated by in the Countess of Chester Hospital had been exceptional in their care. There were specific issues that raised very serious concerns, but the families were at pains to point out that there were other staff who had treated them extremely well. Indeed, as the shadow Health Secretary said, there were staff also raising concerns and ensuring that the police investigated. With NHS England colleagues, we are working closely with the Countess of Chester Hospital on next steps, but it is important that the measures we have taken provide reassurance about the quality of care that is available at Chester now.

I commend the Secretary of State on his decision to upgrade the inquiry and put it on a statutory footing, something I know many of the families wanted. I am keen to understand what steps he can take to give assurances that there is consistency in all hospitals around the UK on the freedom to speak up guardians. What steps is he taking to ensure consistency right across the NHS estate?

My hon. Friend raises an extremely important point. That is why in 2022 the guidance around the national freedom to speak up policy was strengthened —I mentioned the appointment in September 2022 of Henrietta Hughes as the Patient Safety Commissioner—and why significant work has been done on the quality of data, looking at the work for example of the getting it right first time teams, so that the data can be analysed more effectively to alert investigation.

Looking at the timeline, there are further lessons around, for example, who had visibility of the Royal College of Paediatrics and Child Health report and when. Clearly there are further lessons that we need to look at, but already the guidance, particularly on freedom to speak up, has been strengthened. Back in 2018 both the Public Interest Disclosure Act 1998 and alongside it the child death overview panel, which reviews all child deaths, were also strengthened.

As the Secretary of State will be aware, my constituency is served by the Countess of Chester Hospital and many of my constituents work there and are being treated there. There is no doubting the impact this case has had on the whole community, as my hon. Friend the Member for City of Chester (Samantha Dixon) has mentioned. However, as a constituency MP, when I was briefed by the management at the time the issues first emerged, I can say a very different picture was painted from the one we see today. It has been a huge concern that management involved at the time have gone on to work in other parts of the NHS, seemingly with approval from NHS England. I hope the Secretary of State will look into that and that the Kark review recommendations will finally be implemented, because there are serious lessons to be learned from what went on with the senior management.

The hon. Gentleman raises an extremely important point. It is right that we focus on that and ensure that the concerns about the revolving door are addressed. On the decision taken by my predecessor, my understanding is that the recommendations accepted from Kark were viewed as effective in addressing that—obviously, the events to which this statement relates have happened since—but I have asked NHS England colleagues in the Department to look again at testing them further in the light of the evidence that has come through from the court case in particular.

My heartfelt prayers and thoughts are rightly with the families, whose heartbreak and suffering is just unimaginable. I really welcome the tone that the Secretary of State has taken on ensuring that no stone is unturned in the quest for justice. Likewise, I thank him for the support that he has given us in Essex through the Essex mental health trust statutory inquiry that he announced just before recess—we look forward to working with Baroness Lampard on the terms of reference. Can he some provide some assurance so that the 80-plus families who did not engage with the inquiry previously come forward, give evidence and have confidence that their evidence will lead to justice for the loved ones they are missing because of what happened at the mental health trust?

I am keen to give my right hon. Friend that assurance. I know that she has personally championed —as have a number of colleagues across the House—the interests of families in Essex to ensure that they get the answers they need. Indeed, she very effectively conveyed to me the concerns about the inquiry in Essex hitherto. Our focus—I think this is an area of consensus across the House—has to be on ensuring that families get the answers that they legitimately deserve. The reason that it was proportionate to shift the Essex inquiry from a non-statutory footing to a statutory footing was the concern of the chair that there was insufficient engagement, particularly from staff but also, as my right hon. Friend just said, from families who did not have confidence in the inquiry as it was. That is why that inquiry has been strengthened and we have put in a very senior chair with experience of the Savile inquiry. I know that my right hon. Friend will be at the forefront in ensuring that the families’ voices are heard moving forward.

I and my Cheshire West and Chester constituents are served by the Countess of Chester Hospital, so I welcome the inquiry’s having been put on a statutory footing, but like other hon. Members across the House, and, in particular, the families of the victims of this horrendous situation, I want to ensure that those managers who have somehow recycled themselves into leadership positions face stronger regulation and accountability. I look forward to the Secretary of State’s expanding on that.

It will not surprise the hon. Gentleman that a central concern of the families when I met them was the extent to which they felt fobbed off when concerns were raised and the ability of those managers either to continue in post or to move to new posts. I think that concern is shared across the House. It is very much central to some of the safeguards that have been put in place through the recommendations from Kark that have already been accepted. It also opens up questions about the role of boards and how we strengthen non-executive directors, the training and induction, and the other provisions that we can put in place. Of course, some of those issues are the reason we are having the inquiry, and through the statutory process, there will be the opportunity to call people to give evidence and for the judge-led inquiry to put questions on behalf of the families.

I am grateful to my right hon. Friend for the statement and for the announcement of the judge-led inquiry. The shocking murders of those babies and the attempted murders of so many others have shocked the nation. A major concern for me is that managers ignored consultants who had raised serious issues. It appears that there is in some hospitals a culture of people not being listened to when they raise concerns. Dr Stephen Brearey, one of the whistleblowers in this case, says that he has been inundated with emails from people who say that they have not been listened to when they have spoken about really serious issues. I thank the Secretary of State for everything that he has said today, but does he support a strengthening of the whistleblowing legislation so that all whistleblowers know that they will be heard and protected?

To provide some reassurance to my hon. Friend, the Public Interest Disclosure Act 1998 was strengthened in 2018. Obviously, that is post the appalling events covered today, but that Act has already been strengthened. The freedom to speak up guardians have also been implemented since these events, and their role has been strengthened further in the guidance. Significant work has also been done on the role of the child death overview panel and the role of data through the Getting It Right First Time team, picking up data where there are concerns. A significant amount of work has been done on that, but of course through the inquiry, we also need to interrogate more clearly why the concerns raised by clinicians were not acted on by those in leadership positions. I am sure that is something that the judge will want to test in significant detail.

I certainly welcome the Secretary of State’s change of heart on the statutory inquiry: that is vital to get the answers that all the parents deserve. It is also vital that any other parents who have concerns about the treatment of their child when Letby was working at Chester and Liverpool have those concerns fully investigated or reinvestigated by the police, so will the Secretary of State ensure that the Home Secretary provides whatever resources the police need to make that happen?

Given the gravity—the seriousness—of the cases before the House, this issue is something that all Ministers are very seized of, but I will of course relay the right hon. Gentleman’s point to the Home Secretary. From talking to the team, I know that specific funding had been allocated for that in response to the seriousness of these cases, but of course, I will relay that point to my right hon. and learned Friend.

It is impossible to imagine the depths of the grief of the families of the babies who were murdered, and it is absolutely right that we try to help them to get the truth, to find out the facts and to make sure that it does not happen again, so I thank the Secretary of State for agreeing to the statutory inquiry and making sure that the parents are involved. In the Essex case, 2,000 people lost their lives and families have waited many years for that truth, so I thank the Secretary of State for progressing with the statutory inquiry and announcing the new lead of that inquiry today. Can he put that same energy into saying that the families will be involved in the terms of reference; that those terms of reference will be agreed swiftly; and that the inquiry will have the resources it needs to get to the truth, too?

Again, my right hon. Friend raises an extremely important point. I am extremely keen that the families, as well as the Members of Parliament in Essex, are able to engage with the chair of the inquiry and to shape that inquiry.

As part of the discussion in Chester with families about the relative merits of a statutory or a non-statutory inquiry, one concern was that a statutory inquiry sometimes takes much longer, which is why the point around phasing is important. Of course, the court case itself will have established significant areas of factual information that can be used by the inquiry. I hope my right hon. Friend can see that the decision to put the Essex inquiry on to a statutory footing underscores our commitment to getting families the answers they need.

My prayers remain with the families who live each day with the consequences of this unspeakable evil. Among the most chilling aspects of this tragic outrage was, as we have heard, the actions of trust leaders and managers, who ignored warnings and belittled whistleblowers. We have to ask ourselves how many lives could have been saved if people had been believed sooner.

I have to say that this feels horrifically similar to the failings in maternity services in my own local trust of Morecambe Bay during the 2000s, when we saw several mothers and babies needlessly lose their lives. Since then, despite the freedom to speak up measures that have been instituted across the country, I still see whistleblowers in other departments in trusts in the north-west marginalised, bullied, unfairly treated and having their careers trashed, all because it would appear there is a culture of defending the reputation of institutions rather than protecting the safety of patients. What confidence will the Secretary of State give to potential future whistleblowers that, when they speak out in order to save lives, they will not then be singled out?

Again, colleagues across the House know that protecting whistleblowers, including whistleblowers in the NHS, is something I have long championed. As I said earlier, the guidance has been strengthened, but one of the best mitigants is having much more transparency on the data, because the more transparent the data is, the more difficult it is for concerns to be ignored. There is a number of issues. We have strengthened the data. We have the freedom to speak up guardians. We need to look at whether, in Chester, if a freedom to speak up guardian were on the board, that would be the right approach. Do we need to look at whether these roles should be on the board? But significant work has already been done since these events and since Morecambe to strengthen the safeguards around speaking up and the Public Interest Disclosure Act. Alongside that, having organisations such as the Getting It Right First Time team looking at the neonatal data is a further important safety process to have in place.

It is difficult to imagine a more horrendous set of crimes than the ones committed by Letby, and her cowardly refusal to attend her sentence added grievous insult to the huge injury and misery she has caused to all the families. Can we put on record our thanks to the trial judge and the jury for the incredible work they did? I welcome my right hon. Friend’s commitment to a full statutory inquiry under the Inquiries Act 2005 and commend Lady Justice Thirlwall. Does he agree that it is important open justice is maintained fully so that we and the wider public can fully understand what on earth happened here, because this affects not just those families on the indictment—or the victims on the indictment—but hundreds of families across the entire region, and open justice has to be at the heart of judicial process?

First, I join my right hon. and learned Friend in paying tribute to the trial judge and the jury; it must have been a very harrowing case for them to sit on and deal with. He makes, as ever, an important point about open justice. I just have one caveat; I hope he will forgive me. It is that it is also important we get the balance right in respecting the privacy of families where that is their wish, particularly given that quite often these families will have other young children who may or may not know about aspects of this case. So it is important that we have open justice, but at the heart of our approach is ensuring that we are following the wishes of the family, and that includes respecting privacy where that is appropriate.

It is all too tragic, and my prayers are also with the families who have suffered so much over this time. It is 10 years since Sir Robert Francis’s report was published, and of course he put forward the duty of candour, yet the duty of candour of seven consultants was ignored and overridden. As a result of that, will the Secretary of State ensure there is an independent external route through which concern can be raised? Further to that, will he look at the accountability, scrutiny and supervision of clinicians throughout the health service, because the pressures on the service at the moment mean that those vital double checks are often missed?

Again, I agree. It is extremely important that we have the right levels of escalation and the right routes available to those raising concerns. I have already signalled to the House a number of safeguards that have already been put in place following various reviews, including the Francis review. Indeed, I spoke to Sir Robert about the lessons from his report, as I have with a number of other chairs in recent weeks. It is important and a number of safeguards are already in place, but of course the inquiry will look at how those fit together and whether any further steps are required.

I welcome the dashboard the Secretary of State has announced, which will identify outliers so that trusts that have abnormal events can be looked at, but in this particular case the fact that events were happening unexpectedly was identified, staffing analysis was done and seven consultants raised that this was a problem. They identified Lucy Letby as potentially causing this harm and they were repeatedly, repeatedly and repeatedly ignored. We also need to bear it in mind that, if they had not been ignored, some of these babies might not have died, and that is not good enough. As the Secretary of State seeks answers to how this can be prevented, I urge him to focus on three things: how he can develop clear lines of medical, nursing and managerial accountability; how he can prevent poor managers from moving from trust to trust to evade such accountability; and how, if seven consultants find themselves in a similar position in future, they can escalate beyond their trust—outside their trust—to get some attention.

A number of steps have already been taken; I am thinking, for example, of the role of medical examiners working in conjunction with the role of the coroner. Those are the sort of areas that the inquiry will look at: the roles of the coroner, the medical director, the Royal College of Paediatrics and Child Health report in 2016, who had sight of that and what action was taken, and the role of the board, including the non-exec lead, in terms of issues around patient safety. So a range of areas will be looked at, which is the whole purpose of having this inquiry. A number of steps have already been put in place, but it is important that we learn the lesson where clinicians have raised concerns and those concerns were not acted on.

I co-signed a letter to the Health Secretary from Salford MPs and the Salford City Mayor detailing that two senior managers from the Countess of Chester Hospital who were accused, as we have been discussing, of repeatedly ignoring warnings about Ms Letby’s actions then left that hospital and were employed or seconded to NHS trusts in Greater Manchester, including Salford Royal NHS Foundation Trust and the Northern Care Alliance. The two managers were re-employed well after the police had launched their investigation into Lucy Letby. This raises serious questions about NHS governance, HR processes, safety, risk assessment and the role of regulators, as already raised by the Labour Front Bench and my hon. Friend the Member for Weaver Vale (Mike Amesbury). I want to join our concerns from Salford with the concerns the Health Secretary says are already being expressed about the governance issues raised by the re-employment of managers at that time and ask for assurances that this will be fully explored in Justice Thirlwall’s inquiry.

The hon. Lady raises extremely important issues and I am happy to give her the assurance that these issues will be explored. NHS England is looking at that. On the concerns expressed around the regulation of managers, the chief exec of NHS England hosted a meeting last week with key stakeholders to discuss these very issues and I will of course relay to the chief exec the points she has raised.

A few years ago, I was a whistleblower myself against an orthopaedic surgeon in my local hospital who was putting the same metal implant into patients’ backs whether they needed it or not. No other hospital was doing it; the specialist hospital only ever took it out. From that work, I was a parliamentary advocate with my constituent Tim Briggs for Getting It Right First Time. We pushed that for eight years before the NHS took it up, so I am pleased to hear the Secretary of State talking about it. What I discovered then was that the desire of trust management to cover things up to protect the reputation of their institution seemed to trump doing the right thing and throwing the spotlight of transparency on what was happening. What are the key reforms the Secretary of State spoke about today that will mean that will not happen in future and those brave clinicians who spoke up will be listened to in future cases like this?

The key reforms include Getting It Right First Time, the work of Professor Tim Briggs—I raised with him the issue around Chester and the fact that his team have been reviewing that data—the strengthening of the freedom to speak up guardians, the appointment of a new patient safety commissioner, the strengthening of the Public Interest Disclosure Act, the role of child death overview panels and the scrutiny they provide, and the expanded role of medical examiners, which were not in place. So significant actions have been taken, but it is right that through the inquiry we look at the specific issues raised at Chester and any further steps that are appropriate.

When I saw the list of hospitals that the former chief executive of Chester hospital went on to after the Lucy Letby case, I could tell—I speak as a former Health Minister—that it had an eerily familiar ring about it, because failed managers from previous scandals went on to at least some of the same hospitals. Why is the Secretary of State waiting for another review or for the inquiry before finally closing this revolving door and introducing independent regulation for hospital managers similar to that to which medical staff are subjected?

Just to reassure the right hon. Gentleman, it is not that we are waiting. Having discussed it with NHS England, not least in last week’s meeting looking at the Kark recommendations that were accepted and why recommendation 5 was not accepted, the view at the time was that the accepted recommendations were sufficient in addressing the concern about the revolving door. It is right that we test that, but it is also right that we get the balance right.

The right hon. Gentleman mentions concerns that certain trusts may be seen as more difficult to manage. We do not want to create an environment where people are unwilling to go to those more difficult trusts because they fear the risk that they carry. It is important that we get the right support for managers, particularly around some of the more difficult trusts to manage, alongside having the accountability. Getting that detail right requires us to work closely with NHS England and the wider NHS family. [Interruption.]

Order. There is a lot of noise in the Chamber. People who have come in for the next piece of business are forgetting just how very serious and sombre this piece of business is. Have some thought for others.

The Secretary of State has rightly spoken of the enormous pain and suffering of the parents in this horrific case. He will appreciate, however, that during the course of the Lucy Letby trial, they have had to relive all that pain and suffering. As the statutory inquiry progresses, that pain will be continuing for weeks and months ahead. Will the Secretary of State give an assurance to the House that in the period ahead—during the course of the inquiry and beyond—these parents will receive all the support they need to get through this ordeal?

My right hon. Friend is absolutely right about the way that the trial re-triggered a lot of pain and suffering for the families. What I found particularly powerful when talking to them was the fact that they discovered new information during the course of the trial, including harm to their children that they had not been told about hitherto. That was particularly concerning, and clearly serious lessons need to be learned from that. In terms of the support, one of the reasons for wanting to engage with them at the earliest opportunity was to ensure we are doing all we can to support them, and that is central to how I understand the judge will look to structure the inquiry to ensure that the wishes of the families are central to the approach that is taken.

Letby’s crimes freeze the heart, and I commend the Secretary of State for the inquiry being statutory. Although health is devolved, babies from across north Wales are regularly sent to hospitals in north-west England, including the Countess of Chester for specialist care and treatment. What assurance can the Secretary of State give to Welsh families that the statutory inquiry’s terms of reference will include cross-border patient safety and the safety of babies in hospitals possibly hours away from their families in Wales?

I am grateful to the right hon. Lady for raising that extremely important point, because the cases of five of the babies concerned in the trial were cross-jurisdictional. It is important that we take on board those lessons and look at how those cases that apply to a baby or family from Wales are captured, and I know that is something that Judge Thirlwall will give consideration to, shaped by her discussions with the families.

Having a child in neonatal intensive care is absolutely terrifying. A parent in that situation is completely reliant on the professionalism and compassion of the NHS staff, and that is what makes the crimes of Letby so evil and unfathomable. None of us can imagine what the families are going through right now and what they will have to relive during the course of this statutory inquiry. Can the Secretary of State give an assurance to the House that the anonymity of the families will be protected in the course of this inquiry, if they want it to be, so that they can have the privacy they need during this very difficult time?

I absolutely agree with my hon. Friend’s sentiment in putting families and their wishes central. I hope he will understand that as part of an independent inquiry, it will be for the judge to decide which hearings are held in public and which are in private. In essence, part of the initial discussion on a non-statutory inquiry and my discussion with the families was about balancing privacy concerns versus the more adversarial and public nature of a statutory enquiry. I know that Justice Thirlwall will be sensitive to the families’ wishes and what is the appropriate balance between hearings held in public and those held in private.

After all that has happened, it was surely a mistake not to implement recommendation 5 of the Kark review. Why does the Secretary of State not just get on with it and bring it in to disbar senior managers in the NHS?

The Kark recommendations that were accepted, which cover events since those covered at Chester, are believed to have addressed the concerns about the revolving door, but given the issues that have come to light through the case in Chester, I have asked NHSE colleagues to revisit that decision without waiting for the inquiry to look at that. Of course, the inquiry will also look at what is the right balance of regulation for managers.

I wholeheartedly welcome the Secretary of State’s announcement that there will be a full, judge-led statutory inquiry into these horrifying, despicable crimes. It defies belief that senior NHS managers and leaders could have ignored the concerns of senior clinicians in the NHS for so long. I look forward to reassurance that this statutory inquiry will not hold back in holding those senior managers to account, to ensure that this does not happen in any hospital ever again.

I also welcome today’s update that the Essex NHS mental health inquiry has also moved to a statutory footing and that Baroness Lampard will chair that inquiry. Parents will be reassured to know that she is in the House listening to Members’ concerns.

I hope that my hon. Friend will note that the appointment of a Court of Appeal judge underscores the seriousness of the inquiry into the murders by Letby. The decision before the summer to place the Essex inquiry on a statutory footing again underscores our commitment to giving answers to those families in Essex, particularly where there are concerns that staff have hitherto not engaged with the inquiry in the way they need to do.

My thoughts and prayers, and those of my party, are with everyone affected by the unspeakably evil crimes of Lucy Letby. In this instance, we have had a serial killer in play, and that makes it unique, but it is clear that there have been management failings—a failure to listen to senior clinicians, and potentially even a cover-up—and that unfortunately is not a new situation for the NHS. As the MP for North Shropshire, I have seen management failings at the Shrewsbury and Telford Hospital NHS Trust, and my hon. Friend the Member for Westmorland and Lonsdale (Tim Farron) has highlighted the failings at Morecambe Bay. We have had numerous inquiries into management failures in the NHS, we have said “never again” so many times, and we are still here. How can the Secretary of State reassure parents and people being treated in the NHS that this time, when we say “never again”, we will mean it?

Again, I very much agree on the imperative of learning from the various reviews that have taken place. That is why I have personally spoken to the chairs of those reviews over recent days and weeks. I point out that these events took place before a number of the reviews’ recommendations were made and given to the Government, and those recommendations—whether on the medical examiner role, strengthening under the Public Interest Disclosure Act 1998, the use of “get it right first time” to review the data, the freedom to speak up guardians or the new patient safety commissioner role—have been implemented. So significant actions have been taken following those reviews, and those actions have been taken since these events. However, through the inquiry we will of course test whether further action is needed.

As my hon. Friends the Members for City of Chester (Samantha Dixon) and for Ellesmere Port and Neston (Justin Madders) explained, for those of us whose constituents use and work at the Countess, this has been the most dreadful time. But only those who have lost a child could even begin to understand the pain that the families have experienced. It is right that there is unanimity in this House about what is done.

Could I come back to the question asked by my hon. Friend the Member for York Central (Rachael Maskell) about duty of candour? Ten and a half years ago, I stood here in this House and listened to the now Chancellor talk about duty of candour. I am at a loss to understand how it could be that families were not entitled to every bit of information when they asked for it. What review has the Secretary of State already conducted into the effectiveness of duty of candour? What is his conclusion about what has gone wrong over the past 10 years?

As I have said, significant action has been taken over those 10 years to strengthen transparency, action taken on data and the ability of freedom to speak up guardians to ensure that more safeguards are in place. Part of the purpose of the inquiry is to test whether further action is needed. I have already asked NHS England to look again at areas where recommendations have been made and what further action we can take.

First of all, I thank the Secretary of State very much for the tone and the compassion of all his answers. He has encompassed all our thoughts and emotions in a very positive way, and I thank him for that. Can he confirm that any procedural changes that come from lessons learned from this dreadful case will be shared throughout the trust areas? It is a horror that has shaken every parent, pregnant mother and midwife in every corner of this United Kingdom of Great Britain and Northern Ireland. They want to know how they can protect the most vulnerable in our society. How can Government ensure that finances do not preclude precautions being taken to protect babies and also staff on the wards? Will the inquiry’s findings be shared with all devolved Administrations?

I am happy to commit that the inquiry findings will be shared with the Administrations across Great Britain and Northern Ireland. It is important that the lessons are learned. It is also important that we look at where staff move—that includes not just within England but in Northern Ireland—and at where patients from one jurisdiction may be treated in another for a period of time. Those issues apply across the United Kingdom. We should have a UK-wide approach, including to data and looking at variation across the United Kingdom. I know that the hon. Gentleman will take a keen interest in that.