Reports that Matter

About this edition

Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018

How the text was made, and where it falls short

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How the text on Reports that Matter was made, and where it still falls short of the printed page. Nothing has been rewritten. Where we know the text differs from the published report, this page says so.

Last reviewed 12 November 2026 (Volumes I to III added).

The edition

  • Source: the Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018, by the Chair of the Thirlwall Inquiry, the Rt Hon. Lady Justice Thirlwall DBE, ordered to be printed on 15 September 2026, as the Inquiry's PDFs, kept in the report's repository: the Summary report (HC 601, ISBN 978-1-5286-6790-6, 76 A4 pages, SHA-256 a1e1a50e…c2db2), Volume I (HC 597-I, 248 pages, 3a8d0a69…7584b), Volume II (HC 597-II, 309 pages, 7a8199e1…66934) and Volume III (HC 597-III, 217 pages, 7474e14f…7b0e8b); the full checksums are in the repository.
  • Volume III is the edition the Inquiry has linked since 20 October 2026: the September PDF with a two-page correction slip after its contents, correcting the counsel listed for Family Groups 2 and 3 in Appendix 8. The slip is served where it is printed; the list in Appendix 8 (printed p.206) is served as printed, uncorrected, as it is in the PDF.
  • Licence: Crown copyright 2026, reused under the Open Government Licence v3.0, as the imprint on each PDF's third page states.
  • Covers: the whole report, in this order: the Summary report (Chapters 1 to 4), then Volume I (Foreword; Part One, Chapters 1 to 13), Volume II (Part One continued, Chapters 14 to 30) and Volume III (Part Two, Chapters 31 to 44; Part Three, Chapter 45, Recommendations, and Appendices 1 to 9). The Summary report numbers its own chapters 1 to 4, separately from the volumes' 1 to 45. Each volume begins with its title pages and contents as printed.
  • Size: about 335,000 words: the Summary about 38,000, Volume I about 102,000, Volume II about 126,000, Volume III about 69,000. 3,163 numbered paragraphs (433 in the Summary, 1,026 in Volume I, 1,224 in Volume II, 480 in Volume III) and 3,843 notes.
  • Anonymised names (Baby A, Mother A, Nurse W, Dr U and the like) are kept exactly as the report prints them.

How the text was read

  • Born-digital, so the words are the PDF's own. The text layers are clean; no OCR is involved. About 97% of the PDFs' words are in the text here; the rest are the running heads on every page and the furniture of the title pages.
  • Page numbers are the printed ones: roman on each volume's front matter, arabic from the body. In the Summary a printed page is the PDF page less 5; in Volume I, less 7. Each volume numbers its pages from 1 again, so a page number alone is ambiguous across volumes: the site tells them apart in its page anchors.
  • Paragraphs. The report numbers its paragraphs in each chapter ("3.67", "21.5"); each is one citable paragraph, with its number. In the Summary all 433 are present, once each, in order (1.1 to 1.27, 2.1 to 2.153, 3.1 to 3.210, 4.1 to 4.43); in the volumes all 2,730 are present, once each, in order, Chapters 1 to 44 (Chapters 30 and 45 and the appendices do not number their paragraphs). The Summary's paragraphs keep the addresses they were first published with.
  • Page breaks. A page that opens without a paragraph number continues the numbered paragraph above it, even after a full stop (four such pages, PDF pp.8, 10, 51 and 64). Scored against the PDF's own tag tree, 30 page breaks were checked by hand against the PDF: our text is wrong at 1 of 30, the tags at 2 (the cover and title pages).
  • Headings are read from the typeface: the four chapter banners and the sub-headings. Numbered lines are not read as headings (numberedHeadings(false)): the banner "4. Part Two" (PDF p.68) and the contents' entry for it had been read as a heading "Part Two" by its number and words, so Chapter 4 sat a level below the other three and the contents carried a heading (fixed 2026-11-07, reportsthatmatter-hy63). The tagged structure has 50 and 15 sub-headings at two levels; both are set in one face, so the text serves them at one level.
  • Block quotations are read from the layout: the inset italic lines (about 1.4 em in from the body, against a 3.8 em hanging number) are quotations. All 15 the tags mark are served as quote blocks (10 blocks: a quotation of several paragraphs is one block, as the Thematic Review's text over PDF pp.35-36 is in the golden pages). Fixed 2026-11-07, reportsthatmatter-vsd2.
  • The volumes' notes are printed after each chapter, under a heading "Endnotes", numbered from 1 in each chapter. They are read off the page layout and served at the end of the report, each labelled with its note number and chapter. All 3,842 are present, numbered as printed, chapter by chapter, and 3,823 are linked from their markers in the text (the other 19 are next to a symbol footnote's marker; see below).
  • The Summary's one footnote, an asterisk note at the foot of printed p.39 to paragraph 3.67, is served as note 1, linked from its marker after "'Beverly Allitt'." (the site numbers its notes). Fixed 2026-11-07, reportsthatmatter-b1za.
  • Checked against the Inquiry's HTML edition in stage 1: no difference in wording in the Summary, apart from the stray spaces inside about 60 words in the HTML. The volumes' HTML chapters were checked by sample (Chapter 1) and have no such spaces.
  • Line-end hyphens are rejoined from the report's own vocabulary. One Summary word needed a correction once the volumes were added: "post-mortems" (3.102), which the volumes also spell "postmortems".

Known limitations

  • Symbol footnotes in the volumes (about 40 notes marked *, †, ‡, § or doubled, at the foot of the page) are served as paragraphs at the place they are printed, not as notes, and their markers are not linked. Where one sits at the foot of a page that a paragraph runs over, that paragraph is served in two parts (for example 20.9, printed Volume II p.88). Next to 19 of those markers is an ordinary note marker that is therefore not linked either. Bead reportsthatmatter-c08x.
  • Tables and diagrams are flattened. The appendices' tables (Appendix 4, witnesses; Appendix 7, the Inquiry team; Appendix 8, Core Participants; Appendix 9, acronyms) and the figures (organisation charts, the risk matrix in Chapter 15, the health and care system diagram in Chapter 36) are served as runs of text, row and column order mixed, without the table's layout. Bead reportsthatmatter-6gvy.
  • Chapter 45, Recommendations, is set as a two-column table (topic and recommendation, with the chapter that gives the reasons): each recommendation is served as a paragraph opening with its topic ("CCTV and monitoring Recommendation 1 ..."), a long one may be split where it runs over a page, and the chapter references ("Chapter 33") stand as short paragraphs of their own. Bead reportsthatmatter-6gvy.
  • Running heads on a few title and notes pages are served as short paragraphs ("Thirlwall Inquiry", "September 2026", a volume's title).
  • A line mistaken for a heading: "Section 4: Where preliminary inquiries ..." inside 24.1 (quoting the Coroners and Justice Act) is served as a sub-heading, cutting the quotation in two. Bead reportsthatmatter-e9im.
  • Stacked sub-headings read as one (in the Summary, and more in the volumes, such as "Governance framework" over "Council of Governors", Volume I p.3), and two headings that are only a year are lost or run into the paragraph below: "Context" and "The Countess" (PDF p.7), "Further reports" and "Dr Hawdon" (p.50), "2016" with "Thematic Review" (p.35; both read as one paragraph), and "2018" (p.66; the word is missing from the text). Bead reportsthatmatter-e9im.
  • Sub-headings are all at one level, where the tags have two (15 at the lower level in the Summary; in the volumes about 180 of 520), and that level is served one deeper than printed (h4 under the chapter's h2), so that the site's sections are the four chapters; at the printed level the site's section split filed each chapter's opening under the section before. Bead reportsthatmatter-o1jj.
  • Italics are not shown. The report sets quoted evidence in italic; the text here does not carry italics.
  • Cover and imprint pages are served as plain paragraphs before each contents; each volume's title pages therefore end the section before it (Volume I's title pages close the Summary's last section, "4. Part Two").