- Proposals include fitting baby monitors in all neonatal cots and installing CCTV cameras focused on insulin storage units to protect patients.
- Inquiry chair Lady Justice Thirlwall recommended a strict protocol requiring immediate action and police involvement when staff harm is suspected.
- Senior NHS managers should be subject to an individual duty of candour, with guidance to guard against organisational bias when concerns are raised.
- The report calls for mandatory safeguarding training for all trust staff and improved monitoring of child mortality data by March next year.
- Further recommendations suggest unannounced CQC inspections of neonatal services and fully harmonised NHS IT systems by December 2028.
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