Madam Deputy Speaker, I wish to address the findings of a comprehensive three-year public inquiry concerning the Countess of Chester Hospital, which spans the period between 2015 and 2018. This inquiry, led by Lady Justice Thirlwall, has been published today and presents a deeply troubling account of events that have profoundly affected many families.
I would like to express my gratitude to Lady Justice Thirlwall for her diligent and impactful report. Central to this inquiry are the stories of 13 families who lost their newborns or witnessed severe health complications in their infants at the hospital over a decade ago. The depth of grief and suffering experienced by these families is unimaginable.
The mother of Baby J poignantly articulates this loss, stating, “I cannot emphasise enough the impact of this on our whole family, who we are as people, parents, work, life spouses, children. It has cast a shadow of sadness over every part of our lives.” These parents have endured unimaginable hardships, and it is imperative that we acknowledge their years of waiting for the truths revealed in this report.
Context of the Inquiry
This public inquiry was commissioned by the former Health Secretary in September 2023, following the conviction of neonatal nurse Lucy Letby for the murder of seven babies, alongside the attempted murder of six others. Lady Justice Thirlwall has made it clear that her role did not extend to examining the legal proceedings or convictions, nor did it encroach upon the work of the Criminal Cases Review Commission.
Her focus was primarily on the experiences of the parents of the infants cited in the indictment, the conduct of staff at the Countess of Chester Hospital, and the overall effectiveness of NHS management and governance in ensuring the safety of babies in hospital settings. This focus is paramount in our discussions today.
Lady Justice Thirlwall’s findings paint a disheartening picture, revealing a series of repeated failures by both individuals and institutions. The inquiry highlights a concerning rise in neonatal mortality at the hospital during 2015 and 2016, as well as the alarming lack of response from the medical staff when suspicions of deliberate harm were raised.
Failures in Patient Safety
The report exposes shocking inadequacies regarding the prioritisation of infant safety. It outlines failures in safeguarding, governance, and the fundamental duty of candour, alongside a lack of professional curiosity and a failure to refer serious concerns to law enforcement when it was warranted. Lady Justice Thirlwall concludes that many lives could have been saved had appropriate action been taken sooner.
She notes a critical breakdown in safeguarding procedures, stating, “No one seems to have thought that safeguarding action is required when a member of staff is suspected of causing deliberate harm. Suspicion is enough.” The inquiry also calls out external bodies, such as the Care Quality Commission (CQC) and the Royal College of Paediatrics and Child Health, for their inadequate responses and missed opportunities to escalate concerns to the police.
The findings indicate a troubling tendency to deflect responsibility, prioritising institutional reputation over the safety of vulnerable infants. It is deeply concerning that the Trust consistently failed to uphold its obligations to the families affected, withholding crucial information and failing to involve parents in discussions about their infants’ care.
Acknowledgment and Apology
In light of the suffering experienced by these families, I extend a heartfelt apology on behalf of the government and the health service for the failures detailed in the report. The harm, distress, and unimaginable losses suffered by these families are profoundly regrettable, and the failures in safeguarding their babies are unacceptable.
Moving forward, our responsibility is to implement necessary changes. The safety and care of infants, the safeguarding of every patient, and the respect for families are integral to the values of the NHS. These principles must not only be espoused but actively demonstrated in our actions.
Recommendations for Improvement
Lady Justice Thirlwall has put forth 17 recommendations aimed at enhancing the safety of infants in NHS care. While improvements have been made since these tragic events, the inquiry underscores the necessity for further action. I take these recommendations very seriously, and the government will thoroughly review the report to formulate a comprehensive response.
Key areas highlighted include the urgent need for compulsory safeguarding training, revised protocols, and employment standards. I have tasked the Chief Nursing Officer with an immediate review of the NHS safeguarding framework and its training programmes in light of the inquiry’s findings.
However, it is essential to recognise that this issue transcends mere policies and procedures; it is fundamentally about leadership and accountability. Safeguarding is a collective responsibility that must prioritise the safety of our most vulnerable patients.
Enhancing Communication and Support
To bolster safety and reassurance for parents, Lady Justice Thirlwall has recommended the introduction of video baby monitors in neonatal units. I wholeheartedly support this initiative and have instructed my officials to explore the implementation of such technology, which can foster a greater connection between parents and their infants during hospital stays.
The report identifies a need for updated guidelines regarding sudden infant deaths, a recommendation we are already progressing. Furthermore, while the introduction of medical examiners is a positive step, it should have occurred a decade earlier, and we will strive to enhance their expertise in neonatal care.
Other recommendations include stricter regulations surrounding insulin storage and greater oversight of NHS managers, not solely clinical professionals. We will legislate for a barring scheme applicable to senior leaders and managers, ensuring accountability throughout the NHS.
Addressing Implementation Challenges
Lady Justice Thirlwall’s report highlights the failure to act on previous inquiries, prompting my department to establish a recommendation hub to monitor implementation progress across the NHS. We will collaborate with the Cabinet Office to enhance this process in response to this inquiry.
This afternoon, I will engage with the maternity task force to discuss proposed amendments to the health bill aimed at creating a new maternity and neonatal commissioner, addressing the serious concerns regarding safety and standards raised in the inquiry. I will also meet with Lady Justice Thirlwall later this week to discuss the implementation of the report’s conclusions.
Conclusion and Commitment to Change
A particularly concerning aspect of the inquiry revealed that oversight of neonatal care had been diminished during the Countess Hospital’s reorganisation, with the board neglecting to review infant deaths. This oversight indicates a severe governance failure, underscoring the need to elevate the profile of paediatric and neonatal care within our health system.
Madam Deputy Speaker, it is imperative that the safety and wellbeing of infants are never again relegated to a secondary concern. Maternity and neonatal services must occupy a central position within the NHS, prioritising the start of life for families.
I extend my deepest gratitude to the families for their remarkable courage and dignity throughout this ordeal. I also commend Lady Justice Thirlwall and her team for their thorough work. This inquiry represents a pivotal moment for the NHS, where concerns regarding safety must be taken seriously and acted upon promptly. It is time to place maternity and neonatal care at the forefront of the NHS agenda, where it rightfully belongs.