The publication of the Thirlwall inquiry report is above all a moment to remember the babies who died or were harmed at the Countess of Chester hospital and the families whose grief was compounded by years of delay, institutional denial and defensiveness. The least we owe those families is a determination to now make the right changes – not the comfortable ones, not the partial ones, but the ones that will stop further avoidable deaths and injury.

Lady Justice Thirlwall’s report lays bare a total failure of NHS management. When doctors dared to raise concerns, they were rebuked and threatened with referral to the General Medical Council (GMC), which could have ended their career. The report describes a kind of “toxic negativity” all too familiar in the health service: a desperate culture of cover-up and denial that prizes saving face over saving lives.

Whistleblowers deserve respect, not ridicule or rejection. It takes courage to speak out against those in power, and the BMA has supported many such courageous doctors. They include Dr Susan Gilby, who at the very same Countess of Chester hospital refused to stay quiet about the failures she saw around her. She was punished with a shocking........

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