The Thirlwall Inquiry heard evidence from Jane Tomkinson, the newly appointed Chief Executive of the Countess of Chester Hospital (CoCH). Her testimony marked a critical moment in the Inquiry following Lucy Letby's conviction, underscoring the urgent need for reform to ensure patient safety and rebuild trust within the hospital.

Safeguarding Failures Identified

During cross-examination, Ms Tomkinson acknowledged that safeguarding practices at CoCH were inadequate during 2015–2016. She admitted it was "evident from the events of 2015–2016 that safeguarding was not integral to discussions or investigations within the Trust."

Her admission highlighted systemic failures that allowed patient risks to go unaddressed, emphasising the importance of robust safeguarding protocols in all healthcare settings.

Improvements in Culture, Reporting, and Transparency

Ms Tomkinson detailed significant improvements to CoCH's culture, reporting mechanisms, and safeguarding protocols. She described a shift toward inclusivity and openness, stating that the hospital is now "much more open to listening to staff and their concerns."

One of her key priorities as Chief Executive is to enhance patient and staff safety. To this end, she explained that:

• Training to speak up is now mandatory for all staff.
• Reporting mechanisms have been strengthened to encourage transparency.
• Relationships within the organisation are described as positive, fostering a culture where concerns can be escalated promptly.

She reassured the Inquiry that if similar events were to occur today, "paediatricians would be able to escalate immediately to any executive, particularly to me." She also promised that such concerns would receive an "immediate response."

Improved Support for Families and Complaint Resolution

Ms Tomkinson highlighted changes aimed at providing better support to families:

• Transparent communication: Staff are now expected to converse openly with parents regarding their child's care.
• Complaints process: A structured complaints procedure has been implemented, resolving 90% of complaints within 30 days.
• Bereavement support: In 2019, CoCH introduced updated bereavement guidelines, ensuring families experiencing loss receive compassionate, empathetic support.

Strengthened Governance and Incident Reporting

Governance structures have been overhauled to enhance accountability and oversight:

• Daily updates on incidents and deaths are shared with the Executive Team and Board of Directors, ensuring scrutiny of data.
• The Datix incident reporting system is now reviewed daily and frequently audited.
• Safeguarding measures have been reinforced, including a commitment to immediately suspend individuals facing allegations of harm to a child rather than redeploying them to non-frontline roles.

Ms Tomkinson conceded that although policies and processes were in place at the time, "they were not followed." She expressed her support for national standardisation across the NHS and welcomed regulatory frameworks that prioritise patient safety.

How Switalskis Can Help

At Switalskis, we have extensive experience supporting families affected by failings in maternity and neonatal care. We understand the profound impact such experiences can have and are dedicated to helping families seek answers, accountability, and justice.

If you or your family have been impacted by the events at the Countess of Chester Hospital or have concerns about care received at any hospital, our team is here to provide compassionate legal support. Contact us for a confidential conversation about how we can help.

Switalskis is here to help. Call us today at 0800 138 0458 or contact us through our website .