His determination to bring down the consultants meant he “lost objectivity and made poor decisions”, Thirlwall concluded.
She also described it as a “gross misjudgement” when he told Letby: “Lucy, we’ve got your back” after a grievance she had raised was upheld.
The inquiry found his “failure” to take “any responsibility for the delays and the heartache caused to the families” was “indefensible”.
When Chambers resigned in September 2018, he collaborated with trust chair Sir Duncan Nichol on a resignation statement which Thirlwall described as “pure spin”.
It said his departure was “not a judgement on his ability” but “a reflection of his integrity”.
Thirlwall concluded he was in fact resigning to avoid a vote of no confidence.
Chambers later secured senior roles at other NHS trusts, despite what Thirlwall described as “no consideration of whether Chambers was a fit and proper person for the role he was taking on”.