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Inquiry Examines Systemic Failings Enabling Poor Patient Care

An inquiry chair has identified that a prevailing culture within the health system created an environment for inadequate care and criminal acts. The findings suggest issues extended beyond individual institutions.

09/21/2026 · Riverview edition

Lady Justice Thirlwall, who chairs a public inquiry, stated that the culture of the health system fostered conditions enabling both poor care and criminal behavior. She indicated these issues were not isolated to a single hospital.

Her comments suggest a broader systemic context contributed to the circumstances under investigation. The inquiry aims to understand how these conditions developed within the healthcare environment.

Lady Justice Thirlwall outlined how the system's culture permitted these failings. Her observations draw attention to the wider operational framework of healthcare provision.

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