37. The RCPCH made a number of findings which, the RCPCH submits, were, unfortunately, similar to what would be found in comparable units at the time in question.
Is this the part you mean? I think the word unfortunately implies that other units were also very far from optimal, not that any issues were minor, or just less than perfect.
Below is from the Private Eye Special Report Part 6, and quotes from the Thirlwall Inquiry what one set of parents submitted regarding the unit:
But the parents realised their babies were at risk as soon as they arrived. The father attended the caesarean section in June 2016 and told the
inquiry: “The state of the theatres looked like something out of a horror film. It was very cold and unhygienic.” His wife complained about the pain, to which the anaesthetist responded: “It’s not hurting.”
The mother said that when one of the babies later collapsed, “We were confronted by a scene of complete chaos.” When a second triplet collapsed, “I was confronted with the same chaos as the day before.” Her husband observed it was “absolute pandemonium”. “I saw a nurse Googling a procedure, a lung drain. There was an image of a person with an arrow where the incision should
be… I remember other staff coming over to the computer to have a look at it… It looked like they were following a tutorial rather than they actually knew what they were doing.”
Multiple parents have testified that the duty of candour was non-existent at the trust, and they were kept in the dark about safety issues and suspicions on the unit and the risks their babies were being exposed to. Oh, and the blood gas machine on the neonatal unit was broken, sewerage came up through the sink and there was persistent pseudomonas infection.