'Cot cams' could be installed in all neonatal units after Lucy Letby inquiry finds 'complete failure' on unit where she murdered babies

- For the latest on the Thirlwall Report listen to the Mail's award-winning podcast The Trial - See more Daily Mail on Google - save us as a Preferred Source Cot cameras could be fitted in neonatal units across the country to stop another baby serial killer like Lucy Letby. Health Secretary Yvette Cooper said today that she had tasked officials to 'urgently develop plans for cot cams' following a recommendation by Lady Justice Thirlwall. It followed the result of a public inquiry, published by the senior judge earlier today, which found that three babies murdered by Letby could have been saved if NHS managers had called police sooner. uncertain

Making a statement on the Thirlwall Inquiry in the House of Commons, Ms Cooper said she was 'profoundly sorry' for the failures set out in the inquiry and that the scandal has 'has cast a shadow over every part of our lives'. asserted

She added: 'On safety and reassurance for parents, Lady Justice Thirlwall recommends the introduction of video baby monitors for neonatal units. asserted

I agree. asserted

'I have asked my officials to urgently develop plans for cot cams, which can also help parents feel better connected to their babies when they aren't able to be with them in person. asserted

The report makes a series of recommendations, including for cots and incubators in all NHS neonatal units to be fitted with baby monitors to allow parents to observe their baby remotely on a livestream and to act as a 'deterrent to those rare people who seek to harm babies'. asserted

She also said access to insulin in hospitals must be strictly controlled with CCTV cameras installed in fridges. asserted

Lucy Letby was initially found guilty of murdering seven infants and attempting to murder seven more following a ten-month trial at Manchester Crown Court The report is critical of former medical director of the Countess of Chester Hospital Ian Harvey, left, former director of nursing Alison Kelly and former chief executive Tony Chambers Lady Justice Thirlwall arriving at Liverpool Town Hall where she delivered her public inquiry report today In her report, Lady Justice Thirlwall said there had been a 'complete failure' to protect babies at the Countess of Chester Hospital. asserted

She said managers and senior nurses never accepted that consultants' suspicions about Letby could be true – and 'dysfunctional' leadership from the senior executives led to a 'prolonged delay' in contacting police. It was also 'disgraceful' that families of the babies were kept in the dark for years about fears children were being deliberately harmed and the lack of consideration shown to them was 'reprehensible', the senior Appeal Court judge said. uncertain

Instead of alerting the police, bosses prioritised the reputation of the hospital over the babies' safety and commissioned external investigations which failed to discover why they were dying. asserted

Relationships between the consultants raising concerns and executives 'disintegrated,' the judge said. asserted

Instead of being treated as whistleblowers, doctors who continued to raise concerns and demand police be called in were threatened with referrals to the General Medical Council by hospital chiefs and attempts were made to 'manage' them out of their jobs. asserted

Lady Justice Thirlwall said her report was not an investigation into the criminal convictions or guilt of Letby. asserted

The 36-year-old is serving 15 whole-life sentences after being convicted of murdering seven infants and attempting to murder seven more, one of whom she attacked twice, between June 2015 and June 2016. asserted

Lady Justice Thirlwall said up to three children – two triplet brothers known as Baby O and P, and a baby girl known as Baby I – would have lived had hospital bosses not failed to implement proper safeguarding measures. asserted

'After the death of Baby I suspicions became clearer,' the judge said. asserted

'If safeguarding action had been taken, Letby should have been moved from the neonatal unit at this point. asserted

This did not happen. asserted

The collapses and deaths continued. asserted

At an important meeting in May 2016 safeguarding was not considered, and Letby remained on the ward. uncertain

This should not have happened, and babies O and P should not have died. asserted

She agreed with lawyers for the families that an abnormal blood test in August 2015, which showed Letby had poisoned a twin boy, known as Baby F, with insulin represented a 'bright line' in the timeline, after which point no harm should have been allowed to occur. asserted

But the test was 'disregarded' by the consultant who reviewed it, which meant Letby was allowed to continue her killing spree. asserted

She was found by a jury to have harmed up to seven more children – Babies G, H, J, K, L, M and N, at least one of whom was left with brain damage and life-changing injuries – before being removed from the ward, in July 2016. asserted

The failure to spot the significance of the blood test was an opportunity missed, the judge said. asserted

So was an incident in February 2016 when Dr Ravi Jayaram, a doctor who appeared on TV's The One Show and This Morning, failed to report his suspicions about Letby when he walked in on her 'doing nothing' to help a baby girl, whose breathing tube she was later convicted of dislodging. asserted

However, Lady Justice Thirlwall also stressed that even the death of Baby A, in June 2015, would have attracted police involvement had it been reported under sudden death protocols because it was 'unexpected. asserted

' But no one thought the protocol applied in a hospital setting, so no officers were consulted at this stage. asserted

'Had the managers acted as and when they should have, the police would have been involved much sooner,' the judge added. asserted

The 822-page report, which followed seven months of live evidence from more than 130 witnesses, including doctors, nurses, parents of the babies, organisations and experts, plus the examination of thousands of documents and emails, was published today, almost a year later than originally anticipated. asserted

The inquiry is estimated to have cost around £18.5million. asserted

She stressed that her report was not an 'investigation into the criminal convictions or the guilt of Letby,' who has already tried and failed twice to appeal her convictions. asserted

Letby continues to maintain her innocence and the Criminal Cases Review Commission, the organisation that investigates potential miscarriages of justice, is currently reviewing a dossier of evidence submitted by her new defence team. asserted

But Lady Justice Thirlwall said it was not her job to 'second guess' their findings. asserted

She said: 'My report describes dysfunctional management and governance; a gulf between hospital leadership and clinicians; and failure to understand the fundamentals of safeguarding. asserted

She murdered the babies in the hospital between June 2015 to June 2016 The inquiry report, more than 800 pages in length, was released today ' asserted

Many parents take the view that protecting the reputation of the hospital was more important to senior managers than keeping them informed about what was happening. ' asserted

The lack of consideration shown to the parents at that time was reprehensible.' asserted

The judge said 'no one' at the hospital understood that they didn't need to be sure of Letby's guilt before they flagged her link to the spike in deaths as a safeguarding concern. asserted

She added: 'There was complete failure at all levels to invoke safeguarding procedures at any point. ' asserted