Morecambe Bay Investigation

The challenge of providing healthcare in areas that are rural, difficult to recruit to or isolated is not restricted to maternity care and paediatrics. We recommend that NHS England consider the wisdom of extending the review of requirements to sustain safe provision to other services. This is an area lacking in good-quality research yet it affects many regions of England, Wales and Scotland. This should be seen as providing an opportunity to develop and promote a positive way of working in remote and rural environments. Action: NHS England.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England stated that it had concluded "it would not be appropriate to review requirements in the way proposed" because local variations made a single service model unfeasible (DHSC and NHS England, Feb 2026). It noted that work remained underway within pilot integrated care systems on rural workforce transformation, alongside funding formula adjustments to support remote providers (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been completed based on care models and support regimes established by the government (The Thirlwall Inquiry legal team, May 2024).

We believe that the educational opportunities afforded by smaller units, particularly in delivering a broad range of care with a high personal level of responsibility, have been insufficiently recognised and exploited. We recommend that a review be carried out of the opportunities and challenges to assist such units in promoting services and the benefits to larger units of linking with them. Action: Health Education England, the Royal College of Obstetricians and Gynaecologists, the Royal College of Paediatrics and Child Health, the Royal College of Midwives.

In commentary published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team found in its February 2026 review that Health Education England published the findings of its review in spring 2016, which recommended that all trusts and learning education providers continue to support clinical education and training (The Thirlwall Inquiry legal team, Feb 2026).

Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and intrapartum stillbirths and unexpected neonatal deaths. We believe that there is a strong case to include a requirement that investigation of these incidents be subject to a standardised process, which includes input from and feedback to families, and independent, multidisciplinary peer review, and should certainly be framed to exclude conflicts of interest between staff. We recommend that this build on national work already begun on how such a process would work. Action: the Care Quality Commission, NHS England, the Department of Health.

In September 2024, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, citing the Patient Safety Incident Response Framework, the Maternity and Newborn Safety Investigations Programme, and the national Perinatal Mortality Review Tool (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team likewise found that the recommendation had been clearly implemented, noting the creation of the Healthcare Safety Investigation Branch and the introduction of the perinatal review tool (The Thirlwall Inquiry legal team, Feb 2026).

Clear national standards should be drawn up setting out the professional duties and expectations of clinical leads at all levels, including, but not limited to, clinical directors, clinical leads, heads of service, medical directors, nurse directors. Trusts should provide evidence to the Care Quality Commission, as part of their processes, of appropriate policies and training to ensure that standards are met. Action: NHS England, the Care Quality Commission, the General Medical Council, the Nursing and Midwifery Council, all Trusts.

In September 2024, the Department of Health and Social Care and NHS England reported that clinical leadership duties were addressed through professional regulatory guidance, trust inspections, and a February 2024 board competency framework (DHSC and NHS England, Feb 2026). In that same update, they stated that the Care Quality Commission was developing a new assessment framework, while initiatives to widen leadership development across all career stages remained underway (DHSC and NHS England, Feb 2026).

Clear national standards should be drawn up setting out the responsibilities for clinical quality of other managers, including executive directors, middle managers and non-executives. All Trusts should provide evidence to the Care Quality Commission, as part of their processes, of appropriate policies and training to ensure that standards are met. Action: NHS England, the Care Quality Commission, all Trusts.

In February 2026, the Department of Health and Social Care and NHS England reported that the Board Leadership Competency Framework and Our Leadership Way outline standards for leaders, with the Care Quality Commission assessing these areas during inspections (DHSC and NHS England, Feb 2026). They noted that initiatives to widen leadership development for managers at all career stages and work responding to the Messenger Review were still underway (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that although Sir Bruce Keogh had sent an update letter regarding his review of professional codes, a complete report of his assessment could not be found (The Thirlwall Inquiry legal team, May 2024).

A national protocol should be drawn up setting out the duties of all Trusts and their staff in relation to inquests. This should include, but not be limited to, the avoidance of attempts to 'fend off' inquests, a mandatory requirement not to coach staff or provide 'model answers', the need to avoid collusion between staff on lines to take, and the inappropriateness of relying on coronial processes or expert opinions provided to coroners to substitute for incident investigation. Action: NHS England, the Care Quality Commission.

In commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the government has not introduced a national protocol, explaining that existing legislation and professional codes remove the need for one (DHSC and NHS England, Feb 2026). They reported that inquest duties were instead addressed through provider reminders, regulator guidance, and the rollout of medical examiners in September 2024 (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that it could identify no follow-up to the department's initial commitment to consider an additional protocol (The Thirlwall Inquiry legal team, May 2024).

The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it was not within our remit to examine the operation of the NHS complaints system nationally, both the nature of the failures and persistent comment from elsewhere lead us to suppose that this is not unique to this Trust. We believe that a fundamental review of the NHS complaints system is required, with particular reference to strengthening local resolution and improving its timeliness, introducing external scrutiny of local resolution and reducing reliance on the Parliamentary and Health Service Ombudsman to intervene in unresolved complaints. Action: the Department of Health, NHS England, the Care Quality Commission, the Parliamentary and Health Service Ombudsman.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the department did not take forward a fundamental review and "therefore this recommendation was not implemented", noting that the Parliamentary and Health Service Ombudsman had instead issued complaint standards in 2022 (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team recorded in May 2024 that the department had accepted the recommendation in principle in 2015 but maintained that another review would not help (The Thirlwall Inquiry legal team, May 2024).

The division of responsibilities between the Care Quality Commission and other parts of the NHS for oversight of service quality and the implementation of measures to correct patient safety failures was not clear, and we are concerned that potential ambiguity persists. We recommend that NHS England draw up a protocol that clearly sets out the responsibilities for all parts of the oversight system, including itself, in conjunction with the other relevant bodies; the starting point should be that one body, the Care Quality Commission, takes prime responsibility. Action: the Care Quality Commission, NHS England, Monitor, the Department of Health.

In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed (DHSC and NHS England, Feb 2026). They stated that the National Quality Board framework clarifies governance arrangements and brings partners, including the Care Quality Commission, together in System Quality Groups to share intelligence on quality and risk (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team recorded that the department had accepted the proposal in principle, citing its commitments to improve oversight through the board and consolidate patient safety leadership (The Thirlwall Inquiry legal team, May 2024).

The cumulative impact of new policies and processes, particularly the perceived pressure to achieve Foundation Trust status, together with organisational reconfiguration, placed significant pressure on the management capacity of the University Hospitals of Morecambe Bay NHS Foundation Trust to deliver against changing requirements whilst maintaining day-to-day needs, including safeguarding patient safety. Whilst we do not absolve Trusts from responsibility for prioritising limited capability safely and effectively, we recommend that the Department of Health should review how it carries out impact assessments of new policies to identify the risks as well as the resources and time required. Action: the Department of Health.

The Department of Health and Social Care and NHS England stated in September 2024 commentary published in February 2026 that the recommendation had been implemented, explaining that an internal Senior Review Committee evaluates all potential policy impacts, including risks of perverse incentives, alongside extensive quality assurance (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been clearly implemented, citing reforms to the Foundation Trust application process and regulatory oversight (The Thirlwall Inquiry legal team, May 2024).

There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith in her review of the Shipman deaths, but is in our view no less applicable to maternal and perinatal deaths, and should have raised concerns in the University Hospitals of Morecambe Bay NHS Foundation Trust before they eventually became evident. Legislative preparations have already been made to implement a system based on medical examiners, as effectively used in other countries, and pilot schemes have apparently proved effective. We cannot understand why this has not already been implemented in full, and recommend that steps are taken to do so without delay. Action: the Department of Health.

The Investigation recommended the prompt, full implementation of a medical examiner system. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that a statutory medical examiner system rolled out across England and Wales on 9 September 2024 to review all non-coronial deaths, including neonatal deaths (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry reported in September 2026 that the full statutory scheme was operational from that date (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026). Previously, in March 2024, the Expert Panel of the House of Commons Health and Social Care Committee found the recommendation had not been fully met, observing that an extended remit for medical examiners to scrutinise perinatal and maternal deaths was not in place (House of Commons Health and Social Care Committee, Mar 2024; House of Commons Health and Social Care Committee, Mar 2024).

Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, thereby ensuring that appropriate recommendations are made to coroners concerning the occasional need for inquests in individual cases, including deaths following neonatal transfer. Action: the Department of Health.

The Investigation recommended extending the medical examiner system to review stillbirths and neonatal deaths. The Department of Health and Social Care and NHS England stated in commentary of September 2024, published in February 2026, that the recommendation had not been taken forward (DHSC and NHS England, Feb 2026). They explained that while the statutory medical examiner system was introduced in September 2024 for non-coronial deaths, stillbirths cannot be included because stillborn babies are not legally classified as having died (DHSC and NHS England, Feb 2026). In June 2026, Baroness Levitt for the Ministry of Justice stated that the government will consider next steps on coronial investigations of stillbirths after an independent investigation into maternity care led by Baroness Amos reports (Baroness Levitt, Jun 2026).

This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, and the legal basis for handling evidence. These obstacles were overcome, but the need to do this from scratch each time an investigation of this format is set up is unnecessarily time-consuming. We believe that this is an effective investigation format that is capable of getting to the bottom of significant service and organisational problems without the need for a much more expensive, time-consuming and disruptive public inquiry. This being so, we believe that there is considerable merit in establishing a proper framework, if necessary statutory, on which future investigations could be promptly established. This would include setting out the arrangements necessary to maintain independence and work effectively and efficiently, as well as clarifying responsibilities of current and former health service staff to cooperate. Action: the Department of Health.

The Department of Health and Social Care and NHS England reported in commentary published in February 2026 that the Health Services Safety Investigations Body was established in April 2023 with statutory processes for evidence handling and document access, alongside a national internal investigation framework (DHSC and NHS England, Feb 2026). Minister of State Karin Smyth similarly confirmed these arrangements in November 2024 (Karin Smyth, Nov 2024). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).