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Part Two
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Chapter 31Implementation of recommendations of inquiries
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Chapter 32Medical examiners
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Chapter 33CCTV and monitoring
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Chapter 34Insulin
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Chapter 35Data - reading the signals
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Chapter 36The NHS
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Chapter 37Training and regulation of managers
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Chapter 38Duty of candour
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Chapter 39Culture of the NHS
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Chapter 40Freedom to Speak Up Guardians
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Chapter 41Patient safety, safeguarding and employment law
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Chapter 42Care Quality Commission
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Chapter 43The Health Services Safety Investigations Body
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Chapter 44Memorandum of Understanding
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Part Three
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Chapter 45Recommendations
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Appendices
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Appendix 1Terms of reference
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Appendix 2Summary of Nuffield report on Inquiry questionnaire
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Appendix 3The Picker report
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Appendix 4Witnesses who gave oral evidence
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Appendix 5Chair's rulings
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Appendix 6Inquiry process
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Appendix 7Inquiry team
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Appendix 8Core Participants and legal representation
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Appendix 9Acronyms
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Volume III
Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018
Chair: The Rt Hon. Lady Justice Thirlwall DBE
Presented to Parliament pursuant to section 26 of the Inquiries Act 2005
Ordered by the House of Commons to be printed 15 September 2026
HC 597-III