The Secretary of State has apologised to families and set out urgent action on safeguarding, manager regulation and neonatal safety after the Thirlwall Inquiry report was published on 15 September 2026.
The Thirlwall Inquiry report was published on 15 September 2026. It follows a three-year public inquiry into events at the Countess of Chester Hospital between 2015 and 2018. The Secretary of State for Health and Social Care made an oral statement to the House of Commons on the same day.
The inquiry was commissioned in September 2023 by the then Health Secretary, following the conviction of a neonatal nurse for the murder of seven babies and the attempted murder of a further six. The inquiry chair did not examine the convictions, the legal process or the court evidence. The focus was on the experiences of the parents, the conduct of hospital staff, and the effectiveness of NHS management, governance, scrutiny and regulation.
The statement describes the report as a dispiriting and at times shocking account of multiple repeated mistakes and failings by organisations and individuals. It concludes that some babies would have been saved if action had been taken earlier. Central to the findings is what the inquiry chair describes as a complete failure at all levels to invoke safeguarding procedures at any point.
The report 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 identifies failures by the trust in governance, candour and safeguarding, and a repeated failure to refer concerns to the police. It refers to an exercise in spin to steer away from referral to the police. The trust also failed to give parents information they had a right to know, failed to seek their consent for sharing information with external experts, and failed to keep them up to date with investigations.
External bodies are also criticised. The report finds the CQC failed to consider the data and ask the right questions. It finds the Royal College of Paediatrics and Child Health should have known, as soon as it was engaged, that the matter needed to be referred to the police.
The statement also highlights a governance gap at the hospital. The board and the medical director reviewed deaths within the hospital, but only adult deaths. The report says the board did not receive any reports about the deaths of babies and children at any stage during the period under consideration.
The inquiry made 17 recommendations. The government says it will consider the entire report and set out a full response. The Secretary of State highlighted the following actions in the statement:
The inquiry highlights problems with past inquiry recommendations not being implemented. In response, the Department of Health and Social Care is setting up a recommendation hub to track implementation progress internally, covering this inquiry and others across the NHS. The department will also work with the Cabinet Office on improvements in this area.
The Secretary of State said she would discuss with the maternity task force a plan to bring forward amendments in the health bill to create a new maternity and neonatal commissioner. She also said she would meet the inquiry chair later this week to discuss how the conclusions are taken forward.
The statement includes an apology on behalf of the government and the health service for the failures set out in the report. It states that safeguarding is everyone's business and that staff who speak up must be protected and taken seriously. The Secretary of State said she expects every leader, board, professional, manager and member of staff across the NHS to uphold their safeguarding responsibilities.
The inquiry found a complete failure at all levels to invoke safeguarding procedures at any point. It states that suspicion of deliberate harm by a member of staff is enough to require safeguarding action.
The government has confirmed plans for a barring scheme covering senior leaders and managers as well as clinicians. It will legislate as soon as parliamentary time allows and will consider expanding the scheme further.
The report finds the CQC failed to consider the data and ask the right questions. The government says the recommendations for regulators, including the CQC, will be taken seriously.
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