Thirlwall Inquiry

All cots and incubators in all neonatal units should be fitted with baby monitors (in-cot cameras with livestreaming video), so that parents can observe their baby remotely at any time. The funding for this should be centrally managed and ring-fenced, to ensure consistency and implementation across all neonatal units at speed. By 31 March 2027, NHS England should set out a roadmap for how this will be implemented.

In September 2026, Duncan Burton, Chief Nursing Officer for England, and Sarah-Jane Marsh, NHS England Chief Operating Officer, stated that the organisation will "develop a national approach to support neonatal units to implement this", drawing on learning from places where monitors are already used (Duncan Burton; Sarah-Jane Marsh, Sep 2026). This followed an oral statement earlier that month by Yvette Cooper, Secretary of State for Health and Social Care, who accepted the recommendation and directed officials to urgently develop plans for cot cameras (Yvette Cooper response, Sep 2026).

i. Digital devices should be used to restrict access of insulin to authorised people and record access to insulin storage units. I acknowledge that steps are being taken to achieve this. By 31 March 2027, all neonatal units must meet the expected requirements for access control and storage of insulin set out in the NHS England Getting It Right First Time guide, GIRFT Neonatology: Guide to safe insulin use. ii. Until access to insulin requires the provision of biometric data, each Trust should install CCTV cameras focused on storage fridges, cupboards or units. The cameras should store recordings for at least 28 days. iii. The GIRFT Laboratory Handling of Insulin Requests in the Investigation of Hypoglycaemia guidance for the testing and reporting of insulin and C-peptide results, issued in October 2025, must be made mandatory and of national application.

In September 2026, the Department of Health and Social Care accepted the recommendation, with the Secretary of State, Yvette Cooper, stating that the government agreed to introduce stronger controls on insulin storage while beginning work on safe storage guidance (Yvette Cooper response, Sep 2026; Department of Health and Social Care, Sep 2026). Duncan Burton, Chief Nursing Officer for England, and Sarah-Jane Marsh, NHS England Chief Operating Officer, instructed trusts that same month to urgently install CCTV monitoring insulin storage by 30 November 2026 until biometric access is in place (Duncan Burton; Sarah-Jane Marsh, Sep 2026). Under their directive, all neonatal units must meet required access control and storage standards by 31 March 2027 (Duncan Burton; Sarah-Jane Marsh, Sep 2026).

The National Bereavement Care Pathway for neonatal death should be implemented nationally and in all Trusts by 31 August 2027.

Yvette Cooper, Secretary of State for Health and Social Care, stated in September 2026 that all NHS trusts are signed up to implement the National Bereavement Care Pathway for neonatal death by 2027, with the department confirming that rollout is in progress (Yvette Cooper response, Sep 2026; Department of Health and Social Care, Sep 2026). In a letter published that month, Duncan Burton, Chief Nursing Officer for England, and Sarah-Jane Marsh, NHS England Chief Operating Officer, found that integrated care boards and providers should take immediate action to improve care of the bereaved (Duncan Burton; Sarah-Jane Marsh, Sep 2026).

i. NHS England must: a. Immediately inform all Trusts with a neonatal unit that the SUDIC process applies to the sudden and unexpected deaths of babies who have never left hospital. b. Direct all Trusts that they must, within seven days, draw this information to the attention of all relevant staff and the Board. ii. DHSC must complete its review and revision of the SUDIC guidelines and ensure the revised guidelines are distributed to all Trusts by no later than 31 March 2027. The guidelines must include a clear statement that SUDIC applies to sudden and unexpected deaths of babies who have never left hospital. iii. SUDIC forms must be redesigned and shortened to keep bureaucracy to a minimum. The focus should be on what it is essential to know.

In September 2026, Duncan Burton and Sarah-Jane Marsh of NHS England instructed all trusts with a neonatal unit to communicate to relevant staff and their boards by 28 September 2026 that the SUDIC protocol applies to unexpected deaths within those units (Duncan Burton; Sarah-Jane Marsh, Sep 2026). In September 2026, Yvette Cooper confirmed that reviewing and updating the sudden unexpected death in infancy and childhood guidance was "now underway" (Yvette Cooper response, Sep 2026).