The Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018 was presented to Parliament pursuant to section 26 of the Inquiries Act 2005 and ordered by the House of Commons to be printed 15 September 2026.
Summary Report
(Summary Report in Welsh coming soon)
The Report – Volume I
Part One
The Report – Volume II
Part One (continued)
The Report – Volume III
Part Two; Part Three; Appendices
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Volume I
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Foreword
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Part One
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Chapter 1Background
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Chapter 2The neonatal unit, 2015 to 2016
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Chapter 3June 2015: Baby A, Baby B, Baby C and Baby D
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Chapter 4Risk and Patient Safety Department
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Chapter 5August to September 2015: Baby E, Baby F, Baby G and Baby H
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Chapter 6August 2015 to February 2016: Baby I and Baby J; concerns increase; reviews
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Chapter 7Care Quality Commission inspection, February 2016
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Chapter 8February to April 2016: Baby K, Baby L and Baby M
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Chapter 9April to May 2016: The executives
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Chapter 10June 2016: Baby N, Triplets O, P and R
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Chapter 1124 and 25 June 2016: Exchanges between the doctors and managers; Baby Q
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Chapter 12Safeguarding
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Chapter 13Why was action not taken sooner?
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Volume II
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Part One (continued)
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Chapter 14Events at the end of June 2016
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Chapter 15Early July 2016: Discussions; downgrade of the neonatal unit; Silver Command; risk and reputation
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Chapter 16Meetings on 13 and 14 July 2016
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Chapter 17July 2016: Redeployment of and support for Letby
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Chapter 18Nursing and Midwifery Council
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Chapter 19Speak Out Safely
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Chapter 20The RCPCH review
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Chapter 21Reports: Dr Hawdon and Dr McPartland
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Chapter 22September 2016 to January 2017: The grievance
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Chapter 23January to March 2017
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Chapter 24Referral of deaths to the coroner
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Chapter 25NHS England and the Countess
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Chapter 26Contacting the police
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Chapter 27Events in 2018; the Inquiry 2023 to 2026
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Chapter 28The current position
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Chapter 29Bereavement care
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Chapter 30Parents’ further recollections
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Volume III
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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