PARLIAMENTARY DEBATE
Thirlwall Inquiry: Final Report and Recommendations - 15 September 2026 (Commons/Commons Chamber)

May I apologise for the timing of the statement and thank the Opposition for their understanding? With permission, Madam Deputy Speaker, I shall 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 the inquiry have 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:

“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. I recognise that they have waited many years for the details set out in this report and 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 today’s report.

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 that it was not her role to look at the convictions, 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 hospital safe. 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 and 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 the repeated failures of organisations and individuals to act: shocking failures to put the safety of babies first; shocking failures on safeguarding; failures in governance and in regulation; failures in the most basic duty of candour; failures in professional curiosity; and repeated failures to refer concerns to the police, which the inquiry is clear should have been done at a much earlier stage. Lady Justice Thirlwall comes to the devastating conclusion

“that some babies would have been saved…if action was taken earlier.”

Central to the findings are what Lady Justice Thirlwall describes as

“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 Care Quality Commission, which failed to consider the data and ask the right questions, and the Royal College of Paediatrics and Child Health, which should have known as soon as it was engaged that this was a matter that needed to be referred to the police.

The inquiry finds repeated failures of governance and candour by the trust and by individuals within it. Disturbingly, it refers to an “exercise in spin” to steer away from referral to the police. 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; and it failed to ask their consent for sharing information with external experts and other organisations, or to keep them up to date with investigations. For parents to be kept in the dark for years about what was happening is, as Lady Justice Thirlwall has said, “reprehensible”.

Let me address the issues for the families and the parents directly. The suffering endured by the 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 the 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. Let me be clear: the safety and care of babies, the safeguarding of every patient, the respect for families—all those go to the heart of our NHS values. They must be at the heart not just of what we say, but what we do.

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 the terrible events took place, including welcome improvements at the Countess hospital in services for women and children. However, the inquiry is clear that new action is needed.

I take the 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, Lady Justice Thirlwall recommends compulsory training, a new protocol and employment requirements. 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 the report. We need to look urgently at that.

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. I expect every leader, every board across the NHS, every professional, every manager and every member of staff to uphold their safeguarding responsibilities. I will not hesitate to hold the NHS to account for the highest standards at every level, because at its heart, this is what the NHS stands for: care for 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 are unable to be with them in person. The inquiry says that the sudden unexpected death in infancy and childhood guidance must be updated. I agree. That is now under way. It welcomes the introduction of medical examiners but says that this should have happened 10 years earlier. I agree. We will set out further plans to strengthen their neonatal expertise following the inquiry’s recommendations when the Government set out their full response.

The inquiry recommends much stronger controls on insulin storage. The NHS has begun that process with new guidance in January 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 have consulted on and confirmed plans to apply a barring scheme to senior leaders and managers, not just to clinicians. 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. On technology, we have implemented the maternity outcomes signal system, which provides near-real-time safety alerts, but we agree that we must do more. 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 that 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. I will ensure that it is repeated in all versions of the NHS planning framework while I am the Secretary of State.

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. This afternoon I will discuss with the maternity taskforce our plan to bring forward amendments in the Health Bill 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 Lady Justice Thirlwall to discuss how we take forward the report’s conclusions.

I want to highlight a final issue that has struck me while reading through the different volumes of this inquiry. A section of the report 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, this only covered adult deaths. The report says that

“the Board did not receive any reports about the deaths of babies and children at any stage during the period I am 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.”

I am clear that the safety, safeguarding and wellbeing of babies must never again be treated as a side issue. As I reflect on some of the safety reports on maternity services we have seen in recent years, let me also be clear that 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 her team for their rigorous work. This must be a turning point for the NHS. When concerns are raised, especially about safety and 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 they belong. I commend this statement to the House.

Order. Because the ministerial statement ran over, the shadow Secretary of State has six minutes.

I thank the Secretary of State for her statement and for giving me advance sight of it, and we all thank Lady Justice Thirlwall and her team for their incredibly important work. As the Secretary of State said, the report is both thorough and devastating.

These were crimes that shook our whole nation, and no one who has not lost a child in this way could possibly imagine the depth of the parents’ suffering. The task now for the NHS, for the state and for us as parliamentarians is to ensure that from their unthinkably terrible loss will at least come reliable guards against such a tragedy happening again, for sadly this is not the first or only time that serial, tragic, avoidable deaths have occurred within our health service.

There are themes that recur: the dismissal or undermining of whistleblowers; concerns about institutional or personal reputation, or about organisational disruption, hampering the primacy of focus on immediate patient safety; and because the idea of a healthcare worker deliberately harming patients is, naturally, so unthinkable to decent people, alternative explanations are sought instead.

Today we are not at the stage where the Secretary of State is able to say that the Government accept all the recommendations in full, and we understand that it is a very substantial piece of work. She said that they will consider the entire report and set out a full response. When does she anticipate that will happen? In the time available, I will just ask a few questions on a subset of the aspects here. We welcome the points on the suspicion of deliberate harms protocol. The Secretary of State is absolutely right that the message has to get out that, in such cases, suspicion is enough. We must change the way that people think about that.

The report notes that the existing “freedom to speak up” system has operated unevenly through the NHS, and that there remains a need for a national oversight body, although the National Guardian’s Office is no more. The report says that many NHS staff still do not feel that it is possible to raise patient safety concerns without risking career detriment. What else can be done to establish independent escalation pathways outside the management hierarchy? I worry that some of what is there is being removed. If an individual exhausts a trust’s mechanisms for raising concerns, they could currently go to the council of governors at the trust or to NHS England, but both will be abolished by the Health Bill. So if a consultant reports a concern to the board and does not get a hearing, where do they go? Is the Secretary of State the next stage in that line?

I must also ask about another of the Government’s current proposed changes: the abolition of the Health Services Safety Investigations Body. Neither HSSIB nor its predecessor body existed at the time of the murders and, in any event, HSSIB was not set up to investigate individuals, criminal activity or deliberate harm. However, it did create a legally protected safe space for staff to sound alarm bells confidentially outside the normal line manager hierarchy, and that could help to break silences and contribute to the cultural changes that are required. The report states that HSSIB is at present “fulfilling a needed function”, so will the Secretary of State reconsider the proposal to end it?

To many people, an obvious question arising from these terrible cases will surely be that someone up the chain must have noticed the sheer numbers and the severe statistical anomaly in fatalities. The report notes that there was an alert signal in the data in 2015, but the analysis was only being reported on with a long lag. Clearly what is required is real-time reporting and automated analysis to identify abnormalities in deteriorations or unexplained deaths that triggers immediate and independent external review. The Secretary of State mentioned that the near real-time process is now in place. Can she say how close that comes to being fully real-time and automated—though not only automated but, of course, complementing human understanding—to trigger independent external review? The inquiry’s findings on this also link to its recommendation that NHS systems become interoperable by the end of 2028. Does she think that timetable is achievable?

Recommendation 1, as the Secretary of State mentioned, is on the use of cameras in cots, with remote monitoring for parents, and the Department is to set out a road map by March. Remote monitoring has of course become widespread in people’s own homes, and there is cot-side video in use at quite a number of trusts. But this would be rather more than what is typically in place in those hospitals today. Can she outline her initial assessment of how this can be achieved and by when?

One of the most sobering findings is that in Lady Justice Thirlwall’s review of recommendations from previous inquiries into NHS bodies over 30 years, although some significant changes have been made, many recommendations have not been implemented. She supports the formation of a Joint Committee of Parliament to ensure that recommendations are pursued, and she recommends that the National Audit Office audits implementation of statutory inquiries into the NHS. I think I heard the Secretary of State say they were going to create an internal hub—really? I ask her to consider whether that is enough. Would it not be better, in the spirit of the duty of candour, if these things were done through the institutions—through the National Audit Office and with this Parliament?

Our thoughts and prayers remain with all those families in the unimaginable pain of their loss. Although nothing now can undo that pain, it is vital that all possible lessons are learned and, more importantly, acted upon with determination and urgency.

I thank the right hon. Member for his response and questions and for the compassion he shows for the families who have been so badly affected by these terrible events—by the failures in the NHS and the crimes that have taken place.

Our intention is to publish the full response within six months and to ensure that we have done so thoroughly. I will discuss this further with Lady Justice Thirlwall later this week. The issue about whistleblowers, which the right hon. Member raised, is incredibly important. The report states:

“The way the grievance and its consequences were handled was deplorable”

and the way in which the trust responded to these concerns was completely wrong. It also went against the guidance and rules that it was supposed to follow. That is why part of this is about ensuring that the right systems are in place; part of it is also about leadership, responsibility and culture, and ensuring that we are holding all those to account at every level in supporting this, particularly in relation to safeguarding. The safeguarding of babies should have been taken the most seriously of all.

The right hon. Member specifically raised the issues with HSSIB. The inquiry is clear about the important role of HSSIB. The intention of our reforms is for that role to continue. As part of the Health Bill, it involves transferring HSSIB into the Care Quality Commission. However, that independent role and investigations will continue. I plan to review the detail of this to ensure that we are meeting the spirit of the inquiry’s recommendation, because it is immensely important that we have those arrangements in place.

The right hon. Member also referred to the issues around the systems, interoperability and having the data assessments. Of course, we now have new systems in place, including the maternity outcomes signal system. That, when applied to the data that emerged from the Countess of Chester, does make it clear that real-time safety alerts would have been flagged, but of course, in the hospital, the clinicians already knew that a significant increase had taken place, but also they had unexplained deaths and a series of issues that were raised within the hospital. There was a failure of the board to review this, a failure of oversight, a failure of governance and a failure to take proper action.

The right hon. Member raised the recommendation that we need to look at a series of reports. In this case, we know that a series of recommendations have been made, particularly about patient safety and often including whistleblowing. We need to ensure that these recommendations are actually implemented. We must not keep going around in the same circles.

I am conscious that, shockingly, these events took place in 2015 and 2016, very soon after the Lampard review into the NHS, which had made clear the importance of safeguarding. Safeguarding should have been on everybody’s minds at the time, even if the circumstances were very different from what happened here. The issues around safeguarding and patient safety should have been taken incredibly seriously, and they were not. The right hon. Member is right that we need to ensure that systems are in place, but again, even immediately after reports were published, we still had a failure in this case to implement them and to adopt their spirit.

On the recommendations about the NAO, the right hon. Member will know that it is a cross-Government issue. However, I have made it clear that the Department of Health and Social Care will establish a hub for health inquiry recommendations, so that alongside the cross-Government discussion we can ensure that the NHS is doing what it needs to do.

I call Samantha Dixon. I appreciate that this is particularly sensitive for you, so please take your time.

Thank you, Madam Deputy Speaker; I really appreciate that.

This is another very dark day for the families affected by events at the Countess of Chester hospital—those who grieve, who suffer and who continue to live with the terrible fallout. It is crucial for them, as well as every one of my constituents, and those of my right hon. Friend the Member for Alyn and Deeside (Sir Mark Tami) and others, to have absolute confidence that our local hospital—my local hospital—is a safe place.

Lady Justice Thirlwall’s inquiry needs the firmest response possible from Government. She shines a light on a truly appalling state of affairs. Too many times in this place, in response to catastrophic events, we say, “Never again.” I have served previously as Minister for Building Safety, my work guided by the recommendations of the Grenfell tower inquiry. My right hon. Friend the Member for Streatham and Croydon North (Steve Reed) and I argued consistently inside Government for the establishment of a national oversight mechanism to capture the recommendations from important public inquiries, such as this one, to ensure that they are carried forward and are never forgotten or overlooked. Given Lady Justice Thirlwall’s evidence that inquiry recommendations are so often overlooked, will my right hon. Friend the Secretary of State support the calls to broaden her essential recommendation beyond the NHS to all inquiries and set up a national oversight mechanism so that when we say, “Never again,” we mean it?

I thank my hon. Friend for raising this and for consistently speaking out for her constituents who have endured the unimaginable and been through the most horrendous experiences within their families—the loss of a baby, or a collapse—and to then have to go through everything that has happened since and still to have shown, as Lady Justice Thirlwall says, such huge dignity in responding to this inquiry. As the inquiry makes clear, those parents and families have given evidence exactly in the hope that this does not happen again to other families in other hospitals, as well as in Chester, and I pay huge tribute to them.

I will take forward the point that my hon. Friend raised about the cross-Government issues, in discussion with the Cabinet Office—she is right to raise that—and I will undertake to draw together the recommendations from NHS inquiries. I also highlight, because I know it will be important for her constituency, that Lady Justice Thirlwall says:

“in 2025, a large modern women and children’s unit opened, providing integrated family care for babies and their families. This welcome change represents a huge improvement in neonatal care at the Countess.”

That will be hugely important to families in her constituency, but it does not take away from the devastating conclusions of this report and the action that needs to be taken.

I call the Liberal Democrat spokesperson.

I send my heartfelt sympathies and those of my party to all the families who have been so cruelly harmed. I thank Lady Justice Thirlwall for her inquiry and the Secretary of State for early sight of the report.

Lady Justice Thirlwall’s final report is a dispiriting and, at times, shocking account of repeated mistakes and failures by organisations and individuals. The conviction of Lucy Letby for these murders and attempted murders sets this investigation apart from others, but while the situation is incredibly distressing, it is also distressingly familiar—a failure to investigate abnormal levels of death or harm; a failure to act on concerns raised and whistleblowing; a failure to follow established protocols for investigating deaths; and a management instinct to cover up failure, and to put the reputation of the hospital above the safety of the babies in it.

The importance of stronger whistleblowing mechanisms could not be clearer. There should be a duty of candour for management, as well as medical staff. Will the Government accept my amendments to the Health Bill, requiring boards to call in investigators when they receive reports of malpractice, and giving coroners and medical examiners stronger powers to whistleblow? The review makes it explicit that there must be an external body, such as HSSIB, to investigate trusts. Will the Government now drop the measures in the Health Bill that risk patient safety? Surely the Secretary of State will accept the amendments that we and others have put forward to prevent the abolition of HSSIB, protect Healthwatch and put patient safety first, including through the restoration of the National Guardian’s Office.

I am beyond angry that once again we are discussing the recommendations for action following an NHS scandal. It is like groundhog day—we are stuck in an endless cycle of expressing horror and doing nothing, with the reports and recommendations from multiple scandals gathering dust on a shelf in the Department of Health and Social Care. The Thirlwall inquiry cites a “lack of political will” as one of the causes of this cycle. We have a new Secretary of State. Will she promise us that she will be the one to find the will to end this? The families who have suffered such unimaginable loss deserve nothing less.

I thank the hon. Member for her comments, her tribute to the families and her recognition of how much they have endured. She is right to highlight the importance of the duty of candour. One of the most shocking findings of the inquiry was that an “exercise in spin” was put above patient safety, including the safety of some of the most vulnerable patients of all, newborn babies, which is truly shocking. Boards are already responsible for ensuring that they follow the duty of candour. The inquiry found crucial breaches of the board’s duty of candour and responsibilities in a series of areas, including the responsibility to provide information to the reviews done, and safeguarding responsibilities that should have been clear. We will look further at the responsibility framework, the regulation of managers and clinicians, and the leadership’s responsibilities to ensure that what should happen takes place.

The hon. Lady will know that the local guardians remain; that is extremely important. On HSSIB, I agree with her that that role needs to continue. It is the intention for that role to continue as part of the CQC, but I have undertaken to look again at those arrangements to ensure that they meet the expectations of the inquiry’s report.

Fundamentally, the point that the hon. Lady makes is about the anger and sense of deep frustration and injustice about the fact that we are here again, discussing some of the same issues. For me, that is about two things. The first is patient safety, which has been discussed time and again when we have these kinds of recommendations. The second is the sense of the sidelining of maternity and neonatal care, which have been seen as a side issue in too many places, rather than being central. We have to put the cradle back at the heart of the NHS. We have always talked about the NHS being there from cradle to grave. The very start of a child’s life, and the very start of a family’s life, is one of the most important moments, and we have to make sure that our NHS keeps that at the centre of what it does.

My hon. Friend is right to pay tribute to the staff right across our national health service who work immensely hard every day, including in our neonatal units and maternity units, to provide compassion, support and quality care for people who need it at an important time in their life. That includes the staff across the NHS who were devastated when the police investigation, prosecutions and convictions identified terrible crimes taking place, and who are determined to ensure that the best quality of care is provided.

Interestingly, it is an unwillingness to think the unthinkable that is identified as having held some people back from facing up to what happened. It does feel unthinkable that any staff member should deliberately harm a child, but we have a responsibility to be prepared to think the unthinkable. The report identifies that safeguarding arrangements are not a finding of fact; they are a step to be taken when there is a concern or a suspicion—that is when safeguarding action has to be taken, in order to put safety first, and we have to be clear about that right across not just the NHS but all our services. Safeguarding is about what we do when things are still unknown, to put safety first.

My hon. Friend rightly recognises some of the real challenges around culture, concerns about blame, and people having the confidence and support to speak out. Again, the remarks from Lady Justice Thirlwall are really strong on this. It is a responsibility for everyone to ensure that if there are concerns, they are expressed and investigated. That is an act of good faith, not of bad faith. We must all keep patient safety and, above all, the safety of the most vulnerable patients of all—the little babies—in the forefront of our minds. That is what should guide us as we deal with these sensitive issues.