Thirlwall Inquiry: Final Report and Recommendations

Scott Arthur Excerpts

Tuesday 15th September 2026 Commons Chamber

[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.

[Dr Scott Arthur (Edinburgh South West) (Lab)]

This report does not make easy reading, and I cannot imagine how the families feel when they even just look at it. I want to pay tribute to the vast majority of NHS staff right across the UK who do a great job every single day, including my fantastic wife.

The families’ legal team have been very clear that they expect all the recommendations to be implemented, and they are asking for a timeline for that. I know that cannot be given today, but it would be good to hear the Secretary of State say that her ambition is for all the recommendations to be implemented in full as soon as possible. The timeline is really important.

Chapter 39 is about one of the more difficult problems. It talks about culture, and says that in the past, there has been an overreaction to blame culture, which means that some managers have been unwilling to confront bad behaviours. Will the Secretary of State commit to addressing that most difficult of problems?

[Yvette Cooper]

My hon. Friend is right to pay tribute to the staff right across our national health service who work immensely hard every day, including in our neonatal units and maternity units, to provide compassion, support and quality care for people who need it at an important time in their life. That includes the staff across the NHS who were devastated when the police investigation, prosecutions and convictions identified terrible crimes taking place, and who are determined to ensure that the best quality of care is provided.

Interestingly, it is an unwillingness to think the unthinkable that is identified as having held some people back from facing up to what happened. It does feel unthinkable that any staff member should deliberately harm a child, but we have a responsibility to be prepared to think the unthinkable. The report identifies that safeguarding arrangements are not a finding of fact; they are a step to be taken when there is a concern or a suspicion—that is when safeguarding action has to be taken, in order to put safety first, and we have to be clear about that right across not just the NHS but all our services. Safeguarding is about what we do when things are still unknown, to put safety first.

My hon. Friend rightly recognises some of the real challenges around culture, concerns about blame, and people having the confidence and support to speak out. Again, the remarks from Lady Justice Thirlwall are really strong on this. It is a responsibility for everyone to ensure that if there are concerns, they are expressed and investigated. That is an act of good faith, not of bad faith. We must all keep patient safety and, above all, the safety of the most vulnerable patients of all—the little babies—in the forefront of our minds. That is what should guide us as we deal with these sensitive issues.