Thirlwall Inquiry: Final Report and Recommendations

Nusrat Ghani Excerpts

Tuesday 15th September 2026 Commons Chamber

[Several hon. Members rose—]

[Madam Deputy Speaker (Ms Nusrat Ghani)]

Order. Because the ministerial statement ran over, the shadow Secretary of State has six minutes.

--- Later in debate ---

[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.

[Madam Deputy Speaker (Ms Nusrat Ghani)]

I call Samantha Dixon. I appreciate that this is particularly sensitive for you, so please take your time.

[Samantha Dixon (Chester North and Neston) (Lab)]

Thank you, Madam Deputy Speaker; I really appreciate that.

This is another very dark day for the families affected by events at the Countess of Chester hospital—those who grieve, who suffer and who continue to live with the terrible fallout. It is crucial for them, as well as every one of my constituents, and those of my right hon. Friend the Member for Alyn and Deeside (Sir Mark Tami) and others, to have absolute confidence that our local hospital—my local hospital—is a safe place.

Lady Justice Thirlwall’s inquiry needs the firmest response possible from Government. She shines a light on a truly appalling state of affairs. Too many times in this place, in response to catastrophic events, we say, “Never again.” I have served previously as Minister for Building Safety, my work guided by the recommendations of the Grenfell tower inquiry. My right hon. Friend the Member for Streatham and Croydon North (Steve Reed) and I argued consistently inside Government for the establishment of a national oversight mechanism to capture the recommendations from important public inquiries, such as this one, to ensure that they are carried forward and are never forgotten or overlooked. Given Lady Justice Thirlwall’s evidence that inquiry recommendations are so often overlooked, will my right hon. Friend the Secretary of State support the calls to broaden her essential recommendation beyond the NHS to all inquiries and set up a national oversight mechanism so that when we say, “Never again,” we mean it?

[Yvette Cooper]

I thank my hon. Friend for raising this and for consistently speaking out for her constituents who have endured the unimaginable and been through the most horrendous experiences within their families—the loss of a baby, or a collapse—and to then have to go through everything that has happened since and still to have shown, as Lady Justice Thirlwall says, such huge dignity in responding to this inquiry. As the inquiry makes clear, those parents and families have given evidence exactly in the hope that this does not happen again to other families in other hospitals, as well as in Chester, and I pay huge tribute to them.

I will take forward the point that my hon. Friend raised about the cross-Government issues, in discussion with the Cabinet Office—she is right to raise that—and I will undertake to draw together the recommendations from NHS inquiries. I also highlight, because I know it will be important for her constituency, that Lady Justice Thirlwall says:

“in 2025, a large modern women and children’s unit opened, providing integrated family care for babies and their families. This welcome change represents a huge improvement in neonatal care at the Countess.”

That will be hugely important to families in her constituency, but it does not take away from the devastating conclusions of this report and the action that needs to be taken.

[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.