Read the headline findings from the Thirlwall Report in our related article.

The Thirlwall Inquiry was established following the conviction of Lucy Letby, a neonatal nurse at the Countess of Chester Hospital, in connection with the serious harm caused to babies in the unit’s care between 2015 and 2018. Chaired by Lady Justice Thirlwall, the statutory public inquiry examined those events and was presented to Parliament under the Inquiries Act 2005 on 15 September 2026. 

Purpose of the Thirlwall Report  

At its heart, the inquiry sought to understand how those events happened, and what must change to ensure they cannot happen again. 

The inquiry considered three areas: 

1. What was the experience of affected families – what were they told, when, and by whom, and was the Trust sufficiently candid with them throughout? 
2. How did the Board, managers, clinicians and other staff at the Countess of Chester Hospital respond to the concerns that were raised, and could earlier action have been taken to protect babies?
3. Does the current NHS framework of culture, governance, management regulation and external scrutiny effectively keep babies safe – and if not, what must change? 

The Thirlwall Report's key findings: Governance, culture and accountability

The Report’s findings are wide-ranging, but several themes are of direct relevance to all NHS bodies. 

Leaders prioritised reputation over patient safety

Despite credible and repeated concerns being raised by consultant paediatricians, senior managers failed to act. The Report found they were "concerned for the reputation of the hospital," and that this "contributed to the very long delay between those concerns being raised and contacting the police in May 2017." The Report is clear:

No one was willing to think the unthinkable

Witnesses described a collective inability to contemplate deliberate harm by a colleague. The Report warns that this cannot be a cultural norm: "NHS England cannot operate on the basis that harm is unthinkable. It is not." There was no protocol for what to do when deliberate harm was suspected - a gap the Report's recommendations directly address.

Governance structures existed but did not function

The Risk and Patient Safety Department "failed in its fundamental task to enhance patient safety." Despite neonatal mortality rising significantly above expected levels, there was no risk-register entry until July 2016 - a year after the problem had become apparent - and when one was made, reputational risk was scored above patient safety risk.

The Board was not told

The Report is unequivocal: a hospital Board should know about the deaths of babies and children.

Families were not kept informed

The duty of candour was not properly discharged. Parents learned of the review and increased mortality figures through the press. The Report found that across the NHS:

Whistleblowing protections failed in practice

Consultants who raised concerns in good faith were left exposed to recrimination, with the Speak Out Safely Policy not properly engaged. At a national level, many Freedom to Speak Up Guardians lack sufficient protected time, and the 2025 NHS Staff Survey recorded the Freedom to Speak Up sub-score at a five-year low.

Previous inquiry recommendations have not been implemented

The Report reviewed NHS inquiry recommendations stretching back three decades and found that most have not been implemented, with no effective mechanism to track progress or enforce delivery. Lady Justice Thirlwall endorses the House of Lords Statutory Inquiries Committee's description of non-implementation as "inexcusable”.

The 17 recommendations: Obligations by organisation and key dates

The Report makes 17 formal recommendations addressed to a range of bodies. Where available, the key deadlines and obligations are summarised below.

For NHS England

For DHSC

For individual Trusts

For CQC

For the Health and Social Care Committee

For the Parliamentary and Health Service Ombudsman

For the National Audit Office

For the National Medical Examiner

How the government responded to the Thirlwall Report

On 15 September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, made a statement on the Report, expressing gratitude to Lady Justice Thirlwall for her "thorough and devastating report." 

On behalf of the government and the health service, the Secretary of State offered a profound apology:

The Secretary of State described repeated failures of organisations and individuals to act on concerns raised at an early stage, including shocking failures to put the safety of babies first, failures in safeguarding, governance and regulation, failures in the duty of candour, failures in professional curiosity, and repeated failures to refer concerns to the police. Central to the findings, in Lady Justice Thirlwall's own words, was a "complete failure at all levels to invoke safeguarding procedures at any point."

The Secretary of State confirmed that the government will consider the entire report and set out a full response, but highlighted key areas of immediate action. On safeguarding, she noted that a revised NHS safeguarding framework was published in April 2026, but confirmed she had asked the Chief Nursing Officer to urgently review the framework and training in light of the report.

The Secretary of State was clear that this goes beyond laws and procedures, many of which are already clear, and is about leadership and responsibility. She stated:

"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," adding that she expects "every leader, every board across the NHS, every professional, every manager and every member of staff to uphold their safeguarding responsibilities."

On manager accountability and the duty of candour, the Secretary of State acknowledged that boards are already responsible for ensuring they follow the duty of candour. She confirmed that the government:

“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”. 

On HSSIB, the Secretary of State confirmed that she agrees the role needs to continue, and that:

“it is the intention for that role to continue as part of the CQC”, but that she has “undertaken to look again at those arrangements to ensure that they meet the expectations of the inquiry’s report”. 

The debate was marked by deep frustration at the pattern of non-implementation of previous NHS inquiry recommendations. The Opposition described it as:

"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," and cited the Thirlwall inquiry's own reference to "a lack of political will" as one of the causes of this cycle.

The Secretary of State acknowledged that the sense of anger and deep frustration was 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."

She concluded:

"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."

Actions for NHS trusts

Following the above NHS England have written to all trusts and stated they should:

• Install CCTV cameras in neonatal units focussed on storage fridges, cupboards or units by 30 November.
• Inform all relevant staff and the board about the SUDIC protocol by 30 November.
• Ensure all neonatal units meet requirements for access control and storage of insulin by 31 March 2027.
• Consider the Thirlwall Report at the next public board meeting.

The critical message for NHS bodies is this: do not wait. A full government response to all 17 recommendations is still awaited, but NHS leaders should not allow that to become an excuse for inaction. NHS trusts should act now to audit governance frameworks, review escalation routes, and map the report’s recommendations against current practice. The Report offers a clear framework for improvement and action should be taken now. 

Browne Jacobson has extensive experience advising NHS trusts, foundation trusts and other health bodies on governance, regulatory compliance and patient safety matters. If you would like to discuss how the Thirlwall Report affects your organisation, please do get in touch with our health sector team. 

In a related article, our government sector team addresses the impact of the Thirlwall Report on organisations beyond the NHS, focusing on safeguarding responsibilities in local government.