The report of the Thirlwall Public Inquiry has been published and presented to Parliament. The Inquiry was set up to examine events at the Countess of Chester Hospital and their implications following the convictions of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. The report finds that the collapse and deaths of some babies could have been avoided had safeguarding practices been followed and calls for urgent reforms to practices in the operation and supervision of NHS neonatal units. The report makes 17 recommendations, including those covering: CCTV and monitoring; safeguarding and contracts of employment; data reporting; sudden unexpected death in infancy and childhood (SUDIC); suspicion of deliberate harm protocol and guidance; medical examiners; and accountability and regulation of managers.
Read the news story: Inquiry report finds profound failure of management, governance and safeguarding
Read the report and recommendations: Thirlwall Inquiry
Source: The Thirwell Inquiry
Date published: 15 September 2026
