Thirlwall Inquiry

i. By 31 March 2027, all hospital Trusts must have in place effective mechanisms for Board- level monitoring of all deaths of children and babies. ii. By 31 March 2027, all hospital Trusts must have in place a clear and predetermined route to senior management for the escalation of concerning data trends or patterns.

The Inquiry asked National Health Service (NHS) hospital trusts to monitor child deaths. In an oral statement in September 2026, the Secretary of State for Health and Social Care said the government "will, of course, consider the entire report and set out a full response" (Department of Health and Social Care response, Sep 2026). The Minister quoted the Inquiry's finding that the Countess of Chester Hospital board received no reports on infant deaths, but board-level monitoring and escalation routes across trusts are not mentioned in the statement (Department of Health and Social Care response, Sep 2026). The record holds nothing dated later than the response of September 2026 (Department of Health and Social Care response, Sep 2026).

Serious consideration should be given by DHSC to the setting up of a panel of independent experts from all specialties to be called upon in situations where there are emerging concerns about an individual and harm to a patient or patients. A team from any specialty or combination of specialties would be drawn from the panel to conduct a swift, technical investigation into the concerns raised. This may most often be necessary where there are concerns that harm is being or has been caused inadvertently. The precise make-up of the panel should be determined by DHSC but could include, for example: a. two doctors and two nurses from each clinical specialty b. four senior managers c. four pathologists including paediatric and perinatal pathologists d. other experts as decided by DHSC. Where necessary, a small team (always including clinicians from the relevant specialty/ specialties) would be drawn from the panel to carry out an independent investigation into clinical concerns. Such investigations should always include safeguarding considerations (including contacting the police). In addition to reporting their findings to the Trust and DHSC, the experts would be available to be called as witnesses in any proceedings that may follow.2

The Inquiry asked health ministers to consider creating an expert panel on clinical harm. In an oral statement in September 2026, the Secretary of State for Health and Social Care said that the government "will, of course, consider the entire report and set out a full response" (Department of Health and Social Care response, Sep 2026). Made on the day the inquiry report was published, the statement named neither this recommendation nor the proposed panel of independent experts (Department of Health and Social Care response, Sep 2026). The record holds nothing dated later than the response of September 2026 (Department of Health and Social Care response, Sep 2026).

DHSC and NHS England must ensure that, by June 2033, there are 37 doctors in training posts as paediatric and perinatal pathologists, in line with the workforce requirement set out by the Royal College of Pathologists in the November 2025 Paediatric and Perinatal Pathology Workforce Report. The incentive scheme should remain in place and funded until at least 37 doctors are in training posts as paediatric and perinatal pathologists.

The Inquiry asked health authorities to fund 37 paediatric and perinatal pathology training posts. In an oral statement in September 2026, the Secretary of State for Health and Social Care stated that the government "will, of course, consider the entire report and set out a full response" (Department of Health and Social Care response, Sep 2026). Neither the required training posts nor the continuation of the incentive scheme are mentioned in the sources (Department of Health and Social Care response, Sep 2026). A full response from the department remains to be set out (Department of Health and Social Care response, Sep 2026). The record holds nothing dated later than the response of September 2026 (Department of Health and Social Care response, Sep 2026).

There must be a rigorous and consistent review and assessment of the performance of CQC by the Health and Social Care Committee, initially once a year and, once the committee is satisfied, once every three years, or such other frequency to be determined by the select committee.

The Inquiry recommended regular parliamentary reviews of the Care Quality Commission (CQC). In an oral statement in September 2026 on the day the Inquiry report was published, the Secretary of State for Health and Social Care noted that the report makes recommendations for regulators, including CQC (Department of Health and Social Care response, Sep 2026). Addressing further action, the Minister stated that the government "will, of course, consider the entire report and set out a full response" (Department of Health and Social Care response, Sep 2026). The record holds nothing dated later than the response of September 2026 (Department of Health and Social Care response, Sep 2026).

The functions of the National Guardian’s Office should be taken over by the Parliamentary and Health Service Ombudsman in England. The Ombudsman’s powers must be increased to include: a. investigating complaints that whistleblowing in the NHS has not been dealt with adequately b. assisting whistleblowers by referring their concerns to the relevant NHS bodies and overseeing the response.

The Inquiry asked the Parliamentary and Health Service Ombudsman to take over whistleblowing oversight functions. In September 2026, the Secretary of State for Health and Social Care stated that the government "will, of course, consider the entire report and set out a full response" (Department of Health and Social Care response, Sep 2026). The Minister gave this oral statement on the day the report was published, naming neither this recommendation nor the Ombudsman or the National Guardian's Office (Department of Health and Social Care response, Sep 2026). The record holds nothing dated later than the response of September 2026 (Department of Health and Social Care response, Sep 2026).