Government’s Comprehensive Response to the Thirlwall Inquiry Findings

Madam Deputy Speaker, with your permission, I wish to make a statement regarding the report from the three-year public inquiry into the events at the Countess of Chester Hospital occurring between 2015 and 2018. This inquiry was led by Lady Justice Thirlwall and has been published today.

I extend my gratitude to Lady Justice Thirlwall for her meticulous and profoundly impactful report. At its core, this inquiry has centred on the experiences of 13 families who tragically lost their newborn babies or witnessed significant health crises affecting their children at the hospital a decade ago. The depth of grief and suffering experienced by these parents and families is beyond comprehension.

The mother of Baby J poignantly articulates her anguish, stating, “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.” These families have endured unimaginable hardship, and I acknowledge that they have waited far too long for the revelations contained within this report.

Background to the Inquiry

The public inquiry was initiated by the then Health Secretary in September 2023, following the conviction of neonatal nurse Lucy Letby for the murder of seven babies, in addition to the attempted murder of another six. Lady Justice Thirlwall has made it clear that her role did not extend to reviewing these convictions or the legal proceedings involved; rather, her focus was on the parents’ experiences, the conduct of staff at the Countess of Chester Hospital, and the effectiveness of NHS management and governance in ensuring the safety of newborns.

Lady Justice Thirlwall’s report presents a disheartening and at times shocking account of numerous, repeated mistakes and failings by both institutions and individuals. The inquiry highlights a rise in neonatal fatalities at the hospital during 2015 and 2016, alongside early concerns raised by clinicians regarding potential deliberate harm, which were subsequently met with repeated organisational inaction.

There were alarming lapses in putting the safety of infants at the forefront, alongside failures in safeguarding, governance, and the fundamental duty of candour. Moreover, there was a persistent failure to raise concerns with the police, which the inquiry suggests should have been acted upon much sooner. Lady Justice Thirlwall concludes that some infants’ lives could have been saved had appropriate actions been taken earlier.

Failures in Governance and Accountability

The report outlines a complete breakdown in safeguarding procedures, noting that there was an apparent lack of recognition that action should have been taken when suspicions of deliberate harm were raised. Lady Justice Thirlwall states, “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 points to failures by external bodies, such as the Care Quality Commission (CQC), which did not adequately assess the data or pose pertinent questions, as well as the Royal College of Paediatrics and Child Health, which should have referred the matter to the police upon engagement. The findings include disturbing evidence of attempts to divert attention away from the necessity of police involvement.

Madam Deputy Speaker, these findings are utterly appalling. The prioritisation of public relations over the safety of infants is indefensible. Most grievously, the Trust failed to protect the parents, neglecting to keep them informed about their babies’ safety and the ongoing investigations, leaving them in the dark for years. Lady Justice Thirlwall has described this neglect as reprehensible.

Acknowledging the Families’ Suffering

It is imperative to address the families directly, as the suffering experienced by these parents and their babies is unfathomable. On behalf of the government and the health service, I express my deepest sorrow for the failures outlined in this report. The harm, distress, and unimaginable loss endured by these families, along with the failure to safeguard their infants, is utterly regrettable.

Our responsibility now is to take decisive action. It is crucial that the safety and care of infants, the safeguarding of every patient, and the respect for families are embedded into the very ethos of our NHS. These values must not only be articulated but also reflected in our actions.

Implementing Recommendations for Change

Lady Justice Thirlwall has put forward 17 recommendations aimed at improving the safety of babies. The inquiry acknowledges that some progress has been made since these tragic events, particularly with improvements at the Countess Hospital regarding services for women and children. However, it is evident that further actions are essential.

I take these recommendations with utmost seriousness. The government will thoroughly review the entire report and provide a comprehensive response. However, I wish to highlight specific areas of immediate concern. Lady Justice Thirlwall recommends mandatory training, the establishment of a new protocol, and revised employment requirements to enhance safeguarding.

Although a revised NHS safeguarding framework was published in April 2026, I have instructed the Chief Nursing Officer to conduct an urgent review of this framework and the associated training in light of the report’s findings. This issue requires urgent attention.

Prioritising Leadership and Accountability in Safeguarding

It is essential to recognise that this matter extends beyond mere laws and procedures, many of which are already well-defined. It revolves around leadership and accountability. Safeguarding is a collective responsibility that must be prioritised by all. Concerns must be acknowledged and acted upon, and staff who voice their concerns should be safeguarded and taken seriously. I expect every leader, board, professional, and member of staff across the NHS to uphold their safeguarding responsibilities, and I will hold the NHS accountable for maintaining the highest standards at every level. This reflects the core values of the NHS.

Moreover, to enhance parental safety and reassurance, Lady Justice Thirlwall has recommended introducing video baby monitors in neonatal units. I wholeheartedly agree with this recommendation and have tasked my officials with developing plans for cot cameras to help parents feel more connected to their babies when they cannot be present.

Strengthening Regulations and Support Systems

The inquiry has identified the need to update the guidance on sudden and unexpected death in infancy and childhood, and I concur with this necessity; work is already underway in this regard. The introduction of medical examiners, which the inquiry notes should have occurred a decade earlier, will be further strengthened following the recommendations outlined in the report.

Furthermore, the inquiry suggests implementing stricter controls on insulin storage, a process already initiated by the NHS earlier this year with new guidance. We support the recommendation to enhance this further. There is also a call for new regulations concerning NHS managers, not only clinical professionals. The government has consulted on and confirmed plans to introduce a barring scheme applicable to senior leaders and managers, and we will legislate to implement this as soon as parliamentary time permits.

Commitment to Continuous Improvement

The report also addresses the need for improvement among regulators, including the CQC, and these recommendations will be treated with the seriousness they deserve. On the technological front, we have already enacted a maternity outcome signal system to provide near real-time safety alerts, but we recognise the need for further enhancements.

Additionally, I agree with the report’s assertion that when bereavement occurs, parents must be supported to the best of our abilities. The recommendation to roll out the national bereavement care pathway for neonatal death by 2027 is one I fully endorse, and I can confirm that all trusts are committed to implementing this. I will ensure that this commitment is reiterated in all versions of the NHS planning framework during my tenure as Secretary of State.

Establishing a Recommendation Tracking Hub

Finally, Lady Justice Thirlwall underscores the issue of past inquiry recommendations not being implemented. In response, my department is establishing a recommendation hub to properly monitor our implementation progress, not only for this inquiry but for other inquiries across the NHS. We will collaborate with the Cabinet Office to enhance this area in light of the findings from this inquiry.

Madam Deputy Speaker, this afternoon, I will engage with the maternity task force to discuss our plans to introduce amendments in the health bill that will create a new maternity and neonatal commissioner. This initiative aims to address the grave concerns regarding safety and standards that have been raised. Later this week, I will meet with Lady Justice Thirlwall to discuss how we can act on the conclusions of this report.

As I reflect on the various sections of this inquiry, I am particularly struck by the report’s reference to the downgrading of senior oversight of neonatal care during the reorganisation of the Countess Hospital. While the board did review adult deaths, there was a glaring omission of any reports concerning the deaths of infants and children during the inquiry’s timeframe. This oversight represents a serious governance failure that went unnoticed by the board, indicating a significant inadequacy in the structure that silenced the voices of children and infants and diminished the prominence of paediatrics and neonatology.

Madam Deputy Speaker, I am resolute in my belief that the safety, safeguarding, and well-being of infants must never again be relegated to a secondary concern. Furthermore, as I consider the safety reports we have encountered in recent years concerning maternity services, it is evident that maternity and neonatal services cannot exist on the periphery. They must be a central focus of our NHS, particularly during the critical and cherished early stages of family