BMA Chair Says Thirlwall Inquiry Report Shows Need to Regulate NHS Managers

Lady Justice Thirlwall's inquiry report into the deaths and harm of babies at the Countess of Chester Hospital has renewed calls for reform of how NHS managers are regulated, according to an opinion piece by Tom Dolphin, chair of council at the British Medical Association (BMA), published in The Guardian.

Dolphin, a consultant anaesthetist in London, wrote that the report's publication is "above all a moment to remember the babies who died or were harmed" and the families affected by what he described as years of delay, institutional denial and defensiveness.

According to Dolphin, the inquiry report documents a "total failure of NHS management" at the hospital. He wrote that when doctors raised concerns, they were rebuked and threatened with referral to the General Medical Council, a step that could have ended their careers.

Dolphin characterized the culture described in the report as a form of "toxic negativity," which he said reflects a broader pattern within the health service of prioritizing institutional reputation over patient safety.

He argued that non-medical managers are the only safety-critical part of the NHS that currently lacks a regulator, and said Lady Justice Thirlwall has called for that to change. Dolphin said the BMA supports this position.

Dolphin said the response to the inquiry's findings should focus on substantive reforms rather than partial measures, stating that families affected by the case are owed changes that will prevent further avoidable deaths and injuries.