Thirlwall Inquiry: Final Report and Recommendations

Debate between Damian Hinds and Yvette Cooper

Tuesday 15th September 2026 Commons Chamber

[Damian Hinds (East Hampshire) (Con)]

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.

[Yvette Cooper]

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.

Summer Health and Resilience

Debate between Damian Hinds and Yvette Cooper

Wednesday 9th September 2026 Commons Chamber

[Damian Hinds (East Hampshire) (Con)]

I am grateful, Mr Speaker. I thank the Secretary of State for her statement and for advance sight of it. To date, preparedness statements have tended to focus on winter, as she said, but she is right that we now need such an approach for summer.

I welcome the statement today, but we must also ask about this year—the summer just gone. Yes, the intensity and length of high temperatures was new, along with the spikes that it brought in emergency admissions and all the cancelled appointments, but it was also predictable: high temperatures were forecast. What lessons has the Department learned from the UK Health Security Agency reports on adverse weather and health? What preparations had it made in advance of the summer? What guidance was given? Were trusts left to develop protocols themselves? Specifically, what guidance was given to care and nursing homes?

Of course, the high temperatures this summer were not unique to the United Kingdom—nor indeed is the UK, by quite some way, the hottest country in Europe. What conversations have the Secretary of State and her Ministers been having with counterparts in other countries to make sure that each learns from the other?

Right now, the NHS is amid a massive top-down reorganisation. What assessment has the Secretary of State made of the effect of the uncertainty and upheaval that always comes with a major reorganisation on the NHS’s ability to put in place changes at short notice? Given the extreme heat that staff were enduring, what steps is she taking not only on building and ambient temperature, but to ensure that the design of personal protective equipment, for example, reflects the changed needs? What specific consideration is being given to the ambulance service?

There is a connected issue: the cost of energy, for summer as well as winter. What is the right hon. Lady doing across Government to make heating and cooling more affordable for households and individuals? That would bring down admissions. Will the Government now adopt the cheap power plan that we have set out?

Finally, although we are talking about the summer, it is September already; it is reasonable and timely to ask also about winter. We understand that supply of the RSV vaccine is in place, but what guarantees can she give about wider preparedness? When will the Secretary of State come to the House to set out those plans? The number of people waiting more than 12 hours in A&E for admission is up significantly since the change of Government. What is she doing to grip that well ahead of the coming winter pressures?

[Yvette Cooper]

I thank the shadow Secretary of State for his response. As I did not reply to him yesterday, I did not have the opportunity to welcome him to his post. He referred to my personal links to East Hampshire. I should say that I remember going to see the GP at the health centre on Anstey Road in Alton, because of an earache—not that I am associating the right hon. Gentleman with earache.

The shadow Secretary of State raised the issue of this summer. Despite the record demand on the health service in July, there were actually improvements in performance on waiting lists, waiting times and emergency care as a result of the huge amount of planning and work that had been done on performance, particularly for A&E, emergency care and electives. That is a tribute to the work across the national health service and all the planning work that had been done nationally, including to improve performance.

The right hon. Gentleman rightly raised the issue of preparedness for the coming winter. Health Ministers have meetings about the winter in the summer and we are now increasingly going to have to have meetings about summer in the winter as well, but that planning is already well under way right across the NHS and across NHS England. We will provide updates for the House in due course.

The right hon. Gentleman raised some particular issues to do with heat. The NHS approach should be about seasonal resilience to be ready for what might be extremes of flooding, extremes of hot weather and different kinds of conditions that will impact on the country, so that it is able to respond to changing patterns of health need. That is why things such as capital investment are so important in building that greater resilience, which we do not have at the moment because of what we inherited. It is also why we now have a specific heat taskforce to look through the journey on both prevention and how we modernise, and to ensure that the right response is in place right across the NHS.

I am happy to discuss those details further with the shadow Secretary of State as that work progresses. I hope that he will recognise the investment that has gone in over the last two years, in contrast to what we inherited, and the improvements and reforms that are taking place as a result of the changes we have made. I look forward to discussing those with him further.

Timpson Review of School Exclusion

Debate between Damian Hinds and Yvette Cooper

Tuesday 7th May 2019 Commons Chamber

[Damian Hinds]

I totally agree. Rehabilitation is the opportunity for a second chance. What happens in alternative provision is an exceptionally pivotal moment in a young person’s life, which is why the quality of that provision is so important, as is attendance. As I have said, AP is of a very high quality in the great majority of cases.

[Yvette Cooper (Normanton, Pontefract and Castleford) (Lab)]

I welcome the publication of this report, but I am really worried by the number of families coming to me because of real problems with their children not getting special educational needs support in schools. The parents end up having to try to home school their children instead, without the crucial support that they need. There has been a 40% increase in the number of permanent exclusions in my area in just a small number of years, and I cannot see in the Secretary of State’s statement the reassurance for those families that they will get that SEN support by this time next year. What will have changed in the next 12 months to bring the number of exclusions down?

Oral Answers to Questions

Debate between Damian Hinds and Yvette Cooper

Monday 9th January 2017 Commons Chamber

[The Minister for Employment (Damian Hinds)]

We know that one of the most important things in being able to get a job is to have had a job and to have demonstrated employability skills. Specifically on the work experience placements we do through Jobcentre Plus, people spend 49 days longer on average in employment as a result of having done one, so the answer to my hon. Friend’s question is yes.

[Yvette Cooper (Normanton, Pontefract and Castleford) (Lab)]

May I urge the Secretary of State personally to review what is happening to the Motability scheme? Some 41,000 people have had their cars taken away as a result of PIP assessments, including a severely disabled Castleford constituent who now cannot get to work and may be about to lose her job, and a Pontefract constituent with metal rods in her joints who now cannot get out of the house and is at risk of slipping into depression as a result. On the day when the Prime Minister rightly raised the issue of mental health injustice, will he take seriously the serious impact on people’s mental health of being isolated in this way?