Morecambe Bay Investigation

In light of the evidence we have heard during the Investigation, we consider that the professional regulatory bodies should review the findings of this Report in detail with a view to investigating further the conduct of registrants involved in the care of patients during the time period of this Investigation. Action: the General Medical Council, the Nursing and Midwifery Council.

The Department of Health and Social Care and NHS England reported in February 2026 that the General Medical Council and the Nursing and Midwifery Council had completed their investigations into the conduct of the registrants involved (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented, pointing to the regulators' review of the investigation findings and commitment to take appropriate action (The Thirlwall Inquiry legal team, May 2024).

There should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas that are rural, difficult to recruit to, or isolated. This should identify the requirements to sustain safe services under these conditions. In conjunction, a national protocol should be drawn up that defines the types of unit required in different settings and the levels of care that it is appropriate to offer in them. Action: NHS England, the Care Quality Commission, the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of Paediatrics and Child Health, the National Institute for Health and Care Excellence.

In February 2026, the Department of Health and Social Care and NHS England stated that because the 2016 Better Births review showed a single model was unfeasible for rural units, reviewing requirements as proposed was not appropriate (DHSC and NHS England, Feb 2026). They noted that work had instead progressed through a neonatal care review and the 2023 Three Year Delivery Plan for Maternity and Neonatal Services (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found evidence that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).

We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious incidents, both to provide evidence that may otherwise be lacking and to receive personal feedback on the results. Action: the Care Quality Commission, NHS England.

In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that work remained ongoing, highlighting national guidance on patient involvement and the rollout of the Patient Safety Incident Response Framework (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team recorded in the same review that the recommendation had been met, citing the statutory duty of candour and the new incident framework (The Thirlwall Inquiry legal team, Feb 2026). The department noted that a government review of the statutory duty of candour was still underway, alongside planned legislation to establish a duty of candour for public servants (DHSC and NHS England, Feb 2026).

We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the operation of the Trust, including prompt notification of relevant external bodies such as the Care Quality Commission and Monitor. The Care Quality Commission should develop a system to disseminate learning from investigations to other Trusts. Action: the Department of Health, the Care Quality Commission.

In commentary submitted in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England stated that an updated 2022 review framework strengthened information sharing with regulators regarding patient safety risks (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted existing trust reporting requirements and national safety investigation functions (The Thirlwall Inquiry legal team, May 2024). The department had previously reported in March 2020 that the Care Quality Commission did not have a system for disseminating learning to other trusts, although local networks helped share findings (Nadine Dorries, Mar 2020).

We commend the introduction of a clear national policy on whistleblowing. As well as protecting the interests of whistleblowers, we recommend that this is implemented in a way that ensures that a systematic and proportionate response is made by Trusts to concerns identified. Action: the Department of Health.

The Investigation recommended introducing a clear national whistleblowing policy for trusts responding to concerns. In commentary of September 2024, published in February 2026, the Department of Health and Social Care and National Health Service (NHS) England stated that the Thirlwall Inquiry had noted action taken in response to this recommendation (DHSC and NHS England, Feb 2026). In September 2026, the Inquiry reported that "the move towards less national oversight, with the abolition of the NGO, is worrying in this context" (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026).

Professional regulatory bodies should clarify and reinforce the duty of professional staff to report concerns about clinical services, particularly where these relate to patient safety, and the mechanism to do so. Failure to report concerns should be regarded as a lapse from professional standards. Action: the General Medical Council, the Nursing and Midwifery Council, the Professional Standards Authority for Health and Social Care.

In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that implementation was ongoing, noting that joint duty of candour guidance was updated in 2019 and the General Medical Council updated its Good Medical Practice standards in January 2024 to require doctors to report concerns promptly (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that although online records showed an update letter sent to the Secretary of State, a complete report of Sir Bruce Keogh's review of professional codes could not be found (The Thirlwall Inquiry legal team, May 2024).

The Local Supervising Authority system for midwives was ineffectual at detecting manifest problems at the University Hospitals of Morecambe Bay NHS Foundation Trust, not only in individual failures of care but also with the systems to investigate them. As with complaints, our remit was not to examine the operation of the system nationally; however, the nature of the failures and the recent King's Fund review (Midwifery regulation in the United Kingdom) lead us to suppose that this is not unique to this Trust, although there were specific problems there that exacerbated the more systematic concern. We believe that an urgent response is required to the King's Fund findings, with effective reform of the system. Action: the Department of Health, NHS England, the Nursing and Midwifery Council.

In commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented and closed, explaining that the Nursing and Midwifery (Amendment) Order 2017 separated supervision from regulation and that a new non-statutory supervision model, A-EQUIP, had been rolled out across the UK (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).

We considered carefully the effectiveness of separating organisationally the regulation of quality by the Care Quality Commission from the regulation of finance and performance by Monitor, given the close inter-relationship between Trust decisions in each area. However, we were persuaded that there is more to be gained than lost by keeping regulation separated in this way, not least that decisions on safety are not perceived to be biased by their financial implications. The close links, however, require a carefully coordinated approach, and we recommend that the organisations draw up a memorandum of understanding specifying roles, relationships and communication. Action: Monitor, the Care Quality Commission, the Department of Health.

In February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented and closed, confirming that the February 2015 memorandum of understanding between Monitor and the Care Quality Commission still stood and that an information sharing agreement was planned (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found evidence that the measure had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).

The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for concern, in particular the breakdown in communication between the Care Quality Commission and the Parliamentary and Health Service Ombudsman over necessary action and follow-up. We recommend that a memorandum of understanding be drawn up clearly specifying roles, responsibilities, communication and follow-up, including explicitly agreed actions where issues overlap. Action: the Care Quality Commission, the Parliamentary and Health Service Ombudsman.

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, stating that arrangements, including a memorandum of understanding, are in place between the Care Quality Commission and the Parliamentary and Health Service Ombudsman (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).

Organisational change that alters or transfers responsibilities and accountability carries significant risk, which can be mitigated only if well managed. We recommend that an explicit protocol be drawn up setting out how such processes will be managed in future. This must include systems to secure retention of both electronic and paper documents against future need, as well as ensuring a clearly defined transition of responsibilities and accountability. Action: the Department of Health.

The Department of Health and Social Care and NHS England reported in February 2026 that the recommendation was implemented and closed, pointing to an updated Records Management Code of Practice from 2021, a revised departmental Information Management Policy from 2018, and published guidance addressing transfer risks during reorganisations (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).

Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units rely inappropriately on headline mortality figures to reassure others that all is well. We recommend that recording systems are reviewed and plans brought forward to improve systematic recording and tracking of perinatal deaths. This should build on the work of national audits such as MBRRACE-UK, and include the provision of comparative information to Trusts. Action: NHS England.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, noting that perinatal deaths must be reported to MBRRACE-UK within 30 days by place of birth and that a review tool had been adopted across all English trusts (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).

We were concerned by the ad hoc nature and variable quality of the numerous external reviews of services that were carried out at the University Hospitals of Morecambe Bay NHS Foundation Trust. We recommend that systematic guidance be drawn up setting out an appropriate framework for external reviews and professional responsibilities in undertaking them. Action: the Academy of Medical Royal Colleges, the Royal College of Nursing, the Royal College of Midwives.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, following the Academy of Medical Royal Colleges publishing an updated framework for invited reviews in March 2022 (Academy of Medical Royal Colleges, Mar 2022; DHSC and NHS England, Feb 2026). They stated that the guidance provides operating principles for professional bodies conducting reviews across healthcare organisations and should improve the escalation of issues and disclosure to regulators (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).

We further recommend that all external reviews of suspected service failures be registered with the Care Quality Commission and Monitor, and that the Care Quality Commission develops a system to collate learning from reviews and disseminate it to other Trusts. Action: the Care Quality Commission, Monitor.

The Department of Health and Social Care and NHS England stated in February 2026 that joint oversight groups are used with the Care Quality Commission to monitor provider risks, citing a 2022 framework requiring healthcare organisations to alert regulators to concerns found in reviews (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found no record of promised government proposals to mandate notifications, noting that online guidance asking trusts to disclose external reviews as a "matter of course" left it unclear whether compliance was a statutory requirement (The Thirlwall Inquiry legal team, May 2024).

We strongly endorse the emphasis placed on the quality of NHS services that began with the Darzi review, High Quality Care for All, and gathered importance with the response to the events at the Mid Staffordshire NHS Foundation Trust. Our findings confirm that this was necessary and must not be lost. We are concerned that the scale of recent NHS reconfiguration could result in new organisations and post-holders losing the focus on this priority. We recommend that the importance of putting quality first is re-emphasised and local arrangements reviewed to identify any need for personal or organisational development, including amongst clinical leadership in commissioning organisations. Action: NHS England, the Department of Health.

In February 2026, the Department of Health and Social Care and NHS England reported that implementation remained ongoing, highlighting a portfolio of National Quality Board guidance and tools developed to support Integrated Care Systems, including transition guidance and an updated framework for System Quality Groups (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).