Thirlwall Inquiry: Final Report and Recommendations

Helen Morgan Excerpts

Tuesday 15th September 2026 Commons Chamber

[Madam Deputy Speaker (Ms Nusrat Ghani)]

I call the Liberal Democrat spokesperson.

[Helen Morgan (North Shropshire) (LD)]

I send my heartfelt sympathies and those of my party to all the families who have been so cruelly harmed. I thank Lady Justice Thirlwall for her inquiry and the Secretary of State for early sight of the report.

Lady Justice Thirlwall’s final report is a dispiriting and, at times, shocking account of repeated mistakes and failures by organisations and individuals. The conviction of Lucy Letby for these murders and attempted murders sets this investigation apart from others, but while the situation is incredibly distressing, it is also distressingly familiar—a failure to investigate abnormal levels of death or harm; a failure to act on concerns raised and whistleblowing; a failure to follow established protocols for investigating deaths; and a management instinct to cover up failure, and to put the reputation of the hospital above the safety of the babies in it.

The importance of stronger whistleblowing mechanisms could not be clearer. There should be a duty of candour for management, as well as medical staff. Will the Government accept my amendments to the Health Bill, requiring boards to call in investigators when they receive reports of malpractice, and giving coroners and medical examiners stronger powers to whistleblow? The review makes it explicit that there must be an external body, such as HSSIB, to investigate trusts. Will the Government now drop the measures in the Health Bill that risk patient safety? Surely the Secretary of State will accept the amendments that we and others have put forward to prevent the abolition of HSSIB, protect Healthwatch and put patient safety first, including through the restoration of the National Guardian’s Office.

I am beyond angry that once again we are discussing the recommendations for action following an NHS scandal. It is 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. The Thirlwall inquiry cites a “lack of political will” as one of the causes of this cycle. We have a new Secretary of State. Will she promise us that she will be the one to find the will to end this? The families who have suffered such unimaginable loss deserve nothing less.

[Yvette Cooper]

I thank the hon. Member for her comments, her tribute to the families and her recognition of how much they have endured. She is right to highlight the importance of the duty of candour. One of the most shocking findings of the inquiry was that an “exercise in spin” was put above patient safety, including the safety of some of the most vulnerable patients of all, newborn babies, which is truly shocking. Boards are already responsible for ensuring that they follow the duty of candour. The inquiry found crucial breaches of the board’s duty of candour and responsibilities in a series of areas, including the responsibility to provide information to the reviews done, and safeguarding responsibilities that should have been clear. We 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.

The hon. Lady will know that the local guardians remain; that is extremely important. On HSSIB, I agree with her that that role needs to continue. It is the intention for that role to continue as part of the CQC, but I have undertaken to look again at those arrangements to ensure that they meet the expectations of the inquiry’s report.

Fundamentally, the point that the hon. Lady makes is about the anger and sense of deep frustration and injustice about the fact that we are here again, discussing some of the same issues. For me, that is 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. 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.