Thirlwall Inquiry report published

The report into the events of the Countess of Chester Hospital has been published. Within her report, Lady Justice Thirlwall concluded that the deaths of some of the babies at the hospital could have been prevented if safeguarding practices had been followed. The Chair concluded that there had been “complete failure to protect babies on the neonatal unit”.

Lady Justice Thirlwall has made recommendations in 17 areas, including:

• All cots and incubators in all neonatal units should be fitted with baby monitors (in-cot cameras with livestreaming video), so that parents can observe their baby remotely at any time. The funding for this should be centrally managed and ring-fenced, to ensure consistency and implementation across all neonatal units at speed.
• Changes should be made to the monitoring and reporting of deaths of children and babies.
• The Department of Health and Social Care and NHS England must develop and put in place a barring system for all managers (clinical and non-clinical) by September 2027. It should be reviewed in 2030 with a view to moving to a full statutory regulation system by September 2032.
• A new responsibility for auditing the implementation of the recommendations of statutory inquiries into NHS bodies should be given to the National Audit Office. Funding for appropriate additional staffing should be made available so that it may begin its work by September 2027.

The report can be read here.

Jason Beer KC represented NHS England.

Jonathan Dixey and Jennifer Wrightrepresented the Department of Health and Social Care.

Amy Clarke represented the Chief Constable of Cheshire Police.