The Thirlwall Inquiry has published its final report into events at the Countess of Chester Hospital, finding a “complete failure to protect babies” on the neonatal unit. The report sets out 17 recommendations for the NHS, covering safeguarding, governance, and how hospitals respond when staff raise concerns.
The inquiry was established following criminal convictions relating to harm caused to babies on the hospital’s neonatal unit between 2015 and 2016. Its job was not to revisit those convictions, but to examine how the hospital and wider NHS system responded, and what needs to change to ensure it does not happen again.
For many families, a neonatal journey is one of the most challenging and emotional experiences of their lives. This report may bring back memories, raise difficult questions, or cause concern about the treatment that your baby received. If you are worried about any aspect of yours or your baby’s care, there are people ready to listen, support you, and help you to find the answers that you need.
We explain what the inquiry found, and the options available to any parent who has concerns about their own child’s care.
Thirlwall Inquiry finds “Complete failure to protect babies”
The Inquiry has found that a series of serious organisational, leadership and safeguarding failings at the Countess of Chester Hospital allowed concerns about unexplained baby deaths and collapses on the neonatal unit to persist without appropriate action. Consultant paediatricians repeatedly raised concerns about unusual patterns of deaths, unexpected collapses, and the association with Lucy Letby, but senior managers failed to escalate the concerns, delayed involving the police, and prioritised internal reviews and employment processes over patient safety.
The Inquiry concluded that there were multiple missed opportunities to protect babies, and that concerns raised from 2015 onwards should have triggered safeguarding measures and earlier police involvement.
Lady Justice Thirlwall said: “There was a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital.”
Inquiry highlights the importance of parents being heard
The report is also highly critical of the hospital’s lack of candour with families, finding that parents were often not informed about serious incidents, investigations or concerns relating to their babies. It further identified failures by external organisations, including the Care Quality Commission (CQC), the Royal College of Paediatrics and Child Health (RCPCH) and parts of the wider NHS oversight system, which failed to recognise and respond effectively to warning signs.
Charlotte Moore, birth injury lawyer at CL Medilaw, said: “The Thirlwall Inquiry highlights the importance of parents being heard when they raise concerns about their child’s treatment. Families have the right to challenge decisions, demand answers, request second opinions and escalate concerns if they feel they are not being listened to. Patient safety depends not only on staff speaking up, but also on bodies such as NHS Trusts, hospital boards, regulators and commissioners listening carefully to the voices of parents and families.”
What has the Inquiry recommended?
The report makes 17 recommendations aimed at strengthening patient safety and accountability across the NHS. These range from more stringent internal procedures to greater transparency around potential future failings:
- CCTV and in-cot cameras in neonatal units, so parents can see their baby remotely.
- Tighter controls and monitoring of insulin storage.
- Improved real-time tracking of mortality data on neonatal units.
- Stronger safeguarding procedures and earlier police involvement where deliberate harm is suspected.
- A statutory duty of candour for NHS managers, requiring openness with families.
- Stronger regulation of senior NHS leaders, including the potential to bar poorly performing managers.
- Enhanced whistleblowing protections for staff who raise concerns.
- Independent expert panels to investigate concerns about patient harm.
The government responded on the day of publication, with Health Secretary, Yvette Cooper, setting out plans to develop cot cameras for neonatal units, and to legislate for a new barring scheme covering senior NHS managers, and not just clinical staff.
Why this matters if you are worried about your baby's care
While the Inquiry’s findings are specific to one hospital and one period of time, the lessons apply more widely. If concerns raised by staff or parents are not properly escalated, listened to, or acted on, the consequences for babies and families can be devastating.
Parents should know that they don’t need to wait for something to go wrong before raising a concern. Anyone caring for a baby in a neonatal unit, or who has questions about care they received during pregnancy or delivery, has options for getting those concerns heard.
How to raise a concern about your baby’s care
Speak to unit staff first. Most concerns can be raised directly with the nurses, midwives or doctors caring for your baby. Do not feel you need a “good enough” reason. Ask questions, ask for explanations in plain language, and ask for a second opinion if you are not satisfied.
Ask about Family Integrated Care. Many neonatal units now involve parents directly in their baby’s care, which can make it easier to notice and raise concerns early.
Understand Martha’s Rule. Martha’s Rule gives patients, families, and carers the right to a rapid review from a different clinical team if they are worried a patient’s condition is deteriorating and they feel they are not being listened to. It is being rolled out across hospitals in England. In Scotland, Wales and Northern Ireland, equivalent escalation schemes are also in place, such as Call4Concern.
Crucially for families with concerns about the care they received during pregnancy or birth, Martha’s Rule has now been extended to cover maternity care nationwide, following the Ockenden Report into Nottingham University Hospitals NHS Trust.
You can read more about this here: Leading legal expert highlights Martha’s Rule change as “enormous” for families following “harrowing” Ockenden review.
Contact the Patient Advice and Liaison Service (PALS). PALS teams offer confidential advice and support, and can help resolve concerns informally, often while your baby is still receiving care.
Make a formal complaint. If a concern is not resolved informally, you can make a formal complaint through the hospital trust’s complaints procedure. If you remain unhappy with the response, you can escalate to the Parliamentary and Health Service Ombudsman (or the equivalent body in Scotland, Wales or Northern Ireland).
Bliss, the charity for babies born premature or sick, has published a fuller guide covering each of these routes in more detail: Raising concerns about your baby’s care.
Support is available to families
Alongside these routes, some families want independent legal advice, particularly where a baby has been seriously harmed or where a hospital’s response to a concern has fallen short. A birth injury solicitor can help you understand whether the care your baby received met the expected standard, and what options are available if it did not.
This is not a decision you need to make alone, or straight away. Many families speak to a solicitor simply to understand where they stand, without committing to anything further.
Talk to CL Medilaw
If you have concerns about the care you or your baby received during pregnancy, birth or in the neonatal period, our birth injury team is here to listen. We offer a no-obligation conversation to help you understand your options, with no pressure to take things further.
Call 0345 241 0154 or request a callback to speak to a member of our team today.
