Government response to the Thirlwall Inquiry
The Secretary of State has apologised to families and set out urgent action following the Thirlwall Inquiry’s findings, published on 15 September.
Madam Deputy Speaker, with permission, I would like to make a statement on the report of the three-year public inquiry into events at the Countess of Chester Hospital, between 2015 and 2018, led by Lady Justice Thirlwall, published today.
I am grateful to Lady Justice Thirlwall for her thorough and devastating report. At the heart of this inquiry had been 13 families who lost their newborn babies, or who saw them experience serious collapse or injury at the hospital 10 and 11 years ago. I cannot begin to fathom the grief and pain of the parents and families.
The mother of Baby J describes her grief. She says, ‘I cannot emphasise enough the impact of this on our whole family, who we are as people, parents, work, life spouses, children. It has cast a shadow of sadness over every part of our lives.’
Those parents have had to face the unimaginable, and I recognise that they have waited many years for the details set out in this report.
And also that it will continue to add to the distress and the loss that they have endured, they should be in all our thoughts, throughout all the discussions of this report today.
The public inquiry was commissioned by the then Health Secretary in September 2023, following the conviction of neonatal nurse Lucy Letby, for the murder of seven babies, and the attempted murder of a further six babies.
Lady Justice Thirlwall has been clear it was not her role to look at the convictions, or the legal process, or the court evidence. And she is explicit about not cutting across the work of the criminal cases Review Commission.
Instead, her focus was on the experiences of the parents of the babies named in the indictment, the conduct of those working at the Countess of Chester Hospital, including whether action should have been taken earlier, and the effectiveness of NHS management, governance, scrutiny, and regulation, in keeping babies in hospitals safe. And that is also the focus of this statement.
In the words of Lady Justice Thirlwall, the report sets out a dispiriting and, at times, shocking account of multiple repeated mistakes and failings by organisations and individuals.
The inquiry describes the increase in neonatal deaths in 2015 and 2016 at the hospital. The concerns about the possibility of deliberate harm that were raised by clinicians at an early stage, but then repeated failures of organisations and individuals to act.
Shocking failures to put the safety of babies first. Shocking failures on safeguarding. Failures in governance, in regulation, failures in the most basic duty of candour, failures in professional curiosity, and repeated failure to refer concerns to the police, which the inquiry is clear should have been done at a much earliest stage.
And Lady Justice Thirlwall comes to the devastating conclusion that some babies would have been saved if action was taken earlier. Central to these findings are what Lady Justice Thirlwall describes as a complete failure at all levels to invoke safeguarding procedures at any point.
She explains, ‘no one seems to have thought that safeguarding action is required when a member of staff is suspected of causing deliberate harm. Suspicion is enough.’
The inquiry also identifies failure among external bodies, including the CQC, who failed to consider the data and ask the right questions, and the Royal College of Paediatrics and Child Health, who should have known, as soon as they were engaged, that this was a matter that needed to be referred to the police.
The inquiry finds repeated babies of governance and candour by the trust and individuals within it, and disturbingly, it refers to an exercise in spin to steer away from referral to the police.
Madam Deputy Speaker, that is an appalling finding. An exercise in spin, instead of putting the safety of babies first.
Worst of all, the Trust repeatedly failed the parents, it failed to keep their beloved babies safe, it failed repeatedly to provide them with information which they had a right to know, it failed to ask their consent for sharing information with external experts or other organisations, it failed to keep them up to date with investigations that were taking place and for parents to be kept in the dark for years about what was happening is as Lady Justice Thirlwall has said, reprehensible.
So let me address the issues for the families and for the parents directly. Because the suffering endured by these babies and their families is impossible to comprehend. On behalf of the government and the health service, I am profoundly sorry for the failures set out so clearly in this report.
For the harm, distress, and unthinkable loss for their families, and for the failures to keep their babies safe. Our responsibility now is to act, and let me be clear, the safety and care for babies, the safeguarding of every patient, the respect for families. All of these go to the heart of our NHS values, and they must be at the heart, not just of what we say, but what we do.
So let me turn to the recommendations. Lady Justice Thirlwall has made 17 recommendations on what needs to be done to keep babies safe. The inquiry recognises that in many areas, things have changed since these terrible events took place, including welcome improvements at the Countess Hospital in services for women and children.
However, the inquiry is very clear that new action is needed. I take these recommendations extremely seriously. The government will, of course, consider the entire report and set out a full response. But let me highlight some key areas today. On the crucial issue of safeguarding, just as Lady Justice Thirlwall recommends compulsory training, a new protocol, employment requirements.
Madam Deputy Speaker, a revised NHS safeguarding framework was published in April 2026, but I have asked the Chief Nursing Officer to urgently review the framework and the training in the light of this report. We need to look urgently at this.
But let me be clear. This goes beyond laws and procedures, many of which are already clear. This is about leadership and responsibility. Safeguarding is everyone’s business, and safeguarding must be everyone’s priority.
Concerns must be heard and acted upon. Staff who speak up must be protected and taken seriously, and I expect every leader, every board across the NHS, every professional and manager, every member of staff, to uphold their safeguarding responsibilities and I will not hesitate to hold the NHS to account for the highest standards of every level, because at its heart, this is what the NHS stands for.
Careful patients, and most of all, keeping the most vulnerable patients of all safe. On safety and reassurance for parents, Lady Justice Thirlwall recommends the introduction of video baby monitors for neonatal units. I agree. I have asked my officials to urgently develop plans for cot cams, which can also help parents feel better connected to their babies when they aren’t able to be with them in person.
The inquiry says the sudden, unexpected death in infancy and childhood guidance must be updated, I agree. That is now underway. It welcomes the introduction of medical examiners but said it should have happened 10 years earlier. I agree. We will set out further plans to strengthen their neonatal expertise following the inquiries recommendations when the government sets out its full response.
It recommends much stronger controls on insulin storage. The NHS has begun that process with new guidance in January of this year, but we agree with the recommendation to go further.
It recommends new regulation on NHS managers, not just on clinical professionals. The government has consulted on and confirmed plans to apply a barring scheme to senior leaders and managers, not just to clinicians, so we will legislate, to introduce the scheme, as soon as parliamentary time allows, and we will consider the chair’s recommendation to expand it further.
The report also makes recommendations for the regulators, including the CQC, which we will ensure are taken seriously, and on technology. We have implemented the maternity outcome signal system, which provides near real time safety alerts, but we agree. We must do more.
And I agree with the report that when the very worst happens and parents face bereavement, they need to be supported to the best of our ability. The report recommends the national bereavement care pathway for neonatal death should be rolled out in 2027. I agree. and can confirm that all trusts are signed up to implement it, and I will ensure that it is repeated in all versions of the NHS planning framework while I am the Secretary of State.
Finally, Lady Justice Thirlwall highlights problems with past inquiry recommendations not being implemented. So, my department is setting up a recommendation hub to properly track our implementation progress internally, not just for this inquiry, but for others right across the NHS. But we will work with the Cabinet Office now on improvements in this area to respond to this inquiry.
Madam Deputy Speaker, this afternoon, I will discuss with the maternity task force, our plan to bring forward in the health bill amendments to create a new maternity and neonatal commissioner, to address the serious concerns around safety and standards that have been raised. Later this week, I will meet with Justice Thirlwall, to discuss how we take forward the conclusions of this report.
But I want to highlight a final issue that has struck me while reading through the different volumes of this inquiry. Because there is a section of the report that refers to the way senior oversight of neonatal care had been downgraded in the reorganisation of the Countess Hospital.
It includes the fact that the board and the medical director reviewed deaths within the hospital. However, it only covered adult deaths. The report says, ‘The board did not receive any reports about the deaths of babies and children at any stage during the period the inquiry was considering.
This was a serious failure of governance, which no one on the board seems to have noticed. This is further evidence of the inadequacy of the structure, which removed the voice of children and babies from the board, and the lack of profile of paediatrics and neonatology.’
Madam Deputy Speaker, I am clear. The safety and the safeguarding and wellbeing of babies must never again be treated as a side issue.
And as I reflect on some of the safety reports we have seen in recent years on maternity services, let me also be clear. Maternity and neonatal services cannot operate on the margins. They must be at the forefront. A central priority in what our NHS must do at the vital and precious start of a family’s life.
I want to thank the families for the extraordinary courage and dignity they have shown. I also thank Lady Justice Thirlwall and all of her team for their rigorous work. This must be a turning point for the NHS.
When concerns are raised, especially about safety and safety, safeguarding, they must be heard and acted upon. And it is time to put maternity and neonatal care and safety at the top of the NHS agenda, where it belongs.
I commend this statement to the House.