Government response to the Thirlwall Inquiry

The Secretary of State issued a formal apology to 13 families whose newborns died or were harmed at the Countess of Chester Hospital between 2015 and 2018, acknowledging the devastating impact on parents who waited over a decade for answers. The Thirlwall Inquiry, led by Lady Justice Thirlwall, examined systemic failures including missed safeguarding opportunities, poor governance, and a lack of candour by hospital staff and external bodies such as the CQC and the Royal College of Paediatrics and Child Health.

Lady Justice Thirlwall’s report described a pattern of repeated mistakes, including failures to act on early clinician concerns about possible deliberate harm, inadequate safeguarding procedures, and a culture of deflecting responsibility rather than prioritising patient safety. The inquiry concluded that some babies’ lives could have been saved had organisations acted sooner, highlighting a complete failure to invoke safeguarding protocols even when staff were suspected of causing harm.

The government accepted the inquiry’s 17 recommendations and announced immediate steps, including an urgent review of the NHS safeguarding framework by the Chief Nursing Officer, following a revised framework published in April 2026. The Secretary of State emphasised that safeguarding must become a collective responsibility across the NHS, requiring stronger leadership and accountability beyond existing legal and procedural requirements.

The inquiry also criticised the hospital trust for repeatedly failing parents by withholding information, denying consent for data sharing, and keeping families uninformed about investigations for years, describing this as ‘reprehensible.’ The government pledged to address these systemic failures to restore trust and ensure the safety and care of all patients, particularly the most vulnerable.