The Thirlwall inquiry report highlights a critical need for change in NHS management, especially concerning safety-critical roles. Lady Justice Thirlwall asserts that non-medical managers, unlike other safety-critical elements, currently lack regulation. This lack of oversight is seen as a significant flaw, requiring immediate rectification. The report serves as a stark reminder of the tragic infant deaths and harm experienced at the Countess of Chester hospital. Families endured immense grief, exacerbated by prolonged delays and institutional defensiveness. The inquiry reveals a profound failure in NHS management, where concerns raised by doctors were met with threats of professional repercussions. A culture of "toxic negativity," characterized by cover-ups and denial, prioritized reputation over patient well-being. This environment actively discouraged reporting and addressing safety issues. The authors agree with Lady Justice Thirlwall that regulatory changes for non-medical managers are essential. The primary goal of these changes must be the prevention of future avoidable deaths and injuries.