Police were called into the infirmary successful 2017.
Thirlwall added that "no-one seems to person understood that safeguarding enactment is required erstwhile a subordinate of unit is suspected of causing deliberate harm - and does not necessitate colleagues to beryllium definite of guilt".
"All the safeguarding guidance successful the satellite makes nary quality to the information of babies if those to whom concerns are expressed bash nothing."
She highlighted that determination was "still nary NHS-wide protocol connected deliberate harm".
The study recovered Letby had ignored absorption instructions erstwhile she disliked them and shouted astatine her manager.
She had falsified records and 1 babe successful her attraction had been recovered covered successful their ain faeces.
She was besides recovered to person been repeatedly untruthful successful her dealings with friends and colleagues, and was noted by patients to person been "inappropriate" and "callous" successful her manner.
After an probe lasting astir 14 months, detectives arrested the then-28-year-old neonatal portion nurse.
She was arrested 3 times implicit the people of the investigation, and charged with aggregate babe murders and attempted murders successful November 2020.
Her trial, astatine Manchester Crown Court, began successful October 2022 and lasted astir 10 months. The assemblage returned blameworthy verdicts connected 7 counts of execution and six counts of attempted execution - uncovering she had tried to termination 1 babe twice.
She was recovered not blameworthy connected 2 counts of attempted murder, and the assemblage failed to scope verdicts connected six different counts.
Letby was sentenced to 14 full beingness orders, and received a 15th aft she was convicted successful a 2024 retrial for 1 of the attempted murders.
Thirlwall made 17 recommendations successful her report, which ran to implicit 1,100 pages implicit 3 volumes.
She said that cots and incubators successful neonatal units should beryllium fitted with babe monitors, and entree to insulin - which Letby was convicted of administering to 2 of the babies she killed - should beryllium controlled by either biometric information oregon CCTV monitoring.
She besides said a "suspicion of deliberate harm" policy, which outlines the steps to beryllium taken by managers erstwhile suspicions are raised, needed to beryllium created, and that NHS unit should beryllium contractually obligated to travel the argumentation and different safeguarding guidance.
English (US)·