The Letby inquiry report makes one thing crystal clear: too much NHS management is scandalously poor | Tom Dolphin

Non-medical managers are the only safety-critical part of the service that do not have a regulator. Lady Justice Thirlwall says that must change. So do we

• Tom Dolphin is chair of the British Medical Association council

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.

Dr Tom Dolphin is a consultant anaesthetist in London, and chair of council at the BMA