Thirlwall Inquiry Report Published: MAMA Academy Calls for Urgent Action on Neonatal Safety

The final report of the Thirlwall Inquiry was published on Tuesday 15 September 2026, following a three-year public inquiry led by Lady Justice Kathryn Thirlwall into events at the Countess of Chester Hospital between 2015 and 2018.

The inquiry examined the circumstances surrounding the actions of former neonatal nurse Lucy Letby, who was convicted of the murder of seven babies and the attempted murder of seven others. However, the report’s focus extended far beyond individual criminality to examine systemic failures in NHS management, governance, safeguarding and regulation.

Key Findings

Lady Justice Thirlwall concluded there was a “complete failure” to protect babies on the neonatal unit, describing dysfunctional management and governance, a gulf between hospital leadership and clinicians, and a fundamental failure to understand safeguarding.

Most devastatingly, the inquiry found that three babies might have survived and seven others could have been protected if hospital bosses had acted on concerns about Letby sooner. Two newborn twins would not have died and five others would not have been harmed had Letby been removed from the unit earlier. A third baby, a two-month-old girl, and two others who suffered unexplained collapses might have been protected if a doctor had detected an earlier insulin poisoning on the unit.

The report also found that senior doctors who raised concerns were themselves made the subject of investigation in what Thirlwall described as a “deplorable” grievance process, while there was a “prolonged delay” in calling the police. Parents were “kept in the dark” for years about what happened to their babies — a finding Lady Justice Thirlwall described as “reprehensible.”

The inquiry noted that the Board did not receive any reports about the deaths of babies and children during the period under review — a failure of governance that removed the voice of children and babies entirely.

The 17 Recommendations

Lady Justice Thirlwall made 17 recommendations to protect babies and improve neonatal safety:

CCTV and Monitoring: Baby monitors (in-cot cameras with livestreaming video) should be fitted in all cots and incubators across all neonatal units, with centrally managed and ring-fenced funding. NHS England must set out a roadmap by 31 March 2027.

Insulin Safety: Digital devices to restrict access to insulin to authorised people; CCTV focused on insulin storage units; and mandatory national guidance for testing and reporting insulin results.

Bereavement Care: The National Bereavement Care Pathway for neonatal death must be implemented in all Trusts by 31 August 2027.

Safeguarding: Compulsory safeguarding training for all staff and Board members, including on dealing with suspicions of deliberate harm; and employment contract amendments to require following safeguarding guidance.

Technology and Data: Harmonised NHS computer systems by December 2028; Board-level monitoring of all child and baby deaths; a designated “lead reporter” for neonatal data; and near-real-time maternity safety alerts.

SUDIC: Updated guidance on Sudden Unexpected Death in Infancy and Childhood, making clear it applies to babies who have never left hospital.

Suspicion of Deliberate Harm Protocol: A mandatory one-page protocol setting out steps managers must take when concerns are raised about deliberate harm by a healthcare professional.

Expert Panel: A panel of independent experts to be called upon where there are emerging concerns about an individual and harm to patients.

Medical Examiners and Pathologists: A pool of neonatologists to assist medical examiners; and ensuring 37 doctors are in training as paediatric and perinatal pathologists by 2033.

Manager Accountability: A barring system for NHS managers by September 2027, moving to full statutory regulation by 2032; an individual duty of candour for all managers; and an amended NHS Leadership and Management Framework Code putting patients first.

Regulation: Unannounced CQC inspections of hospital departments; rigorous annual assessment of CQC performance by Parliament; and transfer of the National Guardian’s Office functions to the Parliamentary and Health Service Ombudsman.

Implementation: The National Audit Office should audit implementation of statutory inquiry recommendations, with work beginning by September 2027.

Government Response

Speaking in the House of Commons on 15 September, Health and Social Care Secretary Yvette Cooper apologised to families, saying she was “profoundly sorry for the failures set out so clearly in the report, for the harm, distress and unthinkable loss for their families, and for the failures to keep their babies safe.”

Cooper confirmed the Government will consider the entire report and set out a full response, highlighting key commitments including:

• Urgent development of plans for cot-cams in neonatal units
• Updated SUDIC guidance already under way
• Going further on safe use and storage of insulin
• A statutory barring system for NHS senior leaders and managers
• Near-real-time maternity safety alerts through the Maternity Outcomes Signal System
• Improved linked data so deaths in maternity services can be identified and tracked
• All trusts signed up to implement the National Bereavement Care Pathway by 2027
• A new Thirlwall Inquiry Programme Board to coordinate implementation
• A full response to all 17 recommendations to be published in the first half of 2027

Cooper also announced plans to bring forward amendments in the Health Bill to create a new maternity and neonatal commissioner to address concerns around safety and standards.

Statement from Michelle Welsh MP, National Maternity Adviser

Michelle Welsh MP, the Government’s National Maternity Adviser, also responded to the report. She described the suffering endured by the babies and families as “impossible to comprehend” and paid tribute to the families who had fought “with extraordinary dignity for the truth.”

Welsh noted that the Inquiry had exposed “grave failures in governance, safeguarding, regulation and communication with families” and identified structural failures that allowed deaths and harm to go unquestioned for too long.

She confirmed she had been asked by the Secretary of State to chair the beginning of the National Maternity and Neonatal Taskforce meeting on the day of publication while Cooper delivered the statement in the House.

Welsh welcomed the Government’s commitment to act, including on the safe use and storage of insulin; stronger scrutiny of neonatal deaths; near-real-time maternity safety alerts; work to improve linked data; the statutory barring system for NHS leaders; plans for CCTV in individual cots; and examination of how biomarkers could help strengthen controls around medicines.

She emphasised: “Families have waited far too long for answers. They should not have to wait any longer than necessary for meaningful action. Reviews must lead to delivery — not the repetition of familiar findings and promises. Families fought for the truth. We now owe it to them to make sure that truth leads to lasting change.”

Statement from MAMA Academy

Heidi Eldridge, CEO of MAMA Academy, said:

“The Thirlwall Inquiry report is a devastating but necessary read. At MAMA Academy, we know first-hand the life-shattering impact when maternity and neonatal safety fails. The findings of ‘complete failure’ to protect the most vulnerable, the dismissal of clinicians raising concerns, and the years families spent in the dark are not abstract failures — they represent real pain that never needed to happen.

“We welcome Lady Justice Thirlwall’s 17 recommendations, particularly those on bereavement care, safeguarding training, real-time data monitoring, and accountability for managers and regulators. The recommendation that every cot and incubator should have a baby monitor, and that parents must no longer be kept in the dark, resonates deeply with our own mission to empower parents with information and agency.

“MAMA Academy has long campaigned for standardised care across the NHS, because postcode lotteries in maternity and neonatal safety cost lives. Our Pregnancy Passports are already proving what is possible when families are given the tools to advocate for themselves — the Derby and Burton NHS Trust saw a 38% reduction in stillbirths after implementation. Imagine what we could achieve if every family had that same protection.

“We also welcome the Government’s commitment to a full response and the creation of a maternity and neonatal commissioner. But we urge the Government to go further and faster. The first half of 2027 for a full response is too long when babies are at risk today. We need immediate action on safeguarding, on data interoperability, on bereavement care standards, and on the culture that too often treats raising concerns as a problem rather than a duty.

“Michelle Welsh is right: reviews must lead to delivery. MAMA Academy stands ready to work with the NHS, the Government, and families to turn these recommendations into the lasting change our babies deserve.”