-
Foreword
-
Part One
-
Chapter 1Background
-
Chapter 2The neonatal unit, 2015 to 2016
-
Chapter 3June 2015: Baby A, Baby B, Baby C and Baby D
-
Chapter 4Risk and Patient Safety Department
-
Chapter 5August to September 2015: Baby E, Baby F, Baby G and Baby H
-
Chapter 6August 2015 to February 2016: Baby I and Baby J; concerns increase; reviews
-
Chapter 7Care Quality Commission inspection, February 2016
-
Chapter 8February to April 2016: Baby K, Baby L and Baby M
-
Chapter 9April to May 2016: The executives
-
Chapter 10June 2016: Baby N, Triplets O, P and R
-
Chapter 1124 and 25 June 2016: Exchanges between the doctors and managers; Baby Q
-
Chapter 12Safeguarding
-
Chapter 13Why was action not taken sooner?
-
Volume I
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-I