Completed
· Chair: Lady Justice Thirlwall
· Established October 2023
· Commissioned by Department of Health and Social Care
Statutory inquiry into events at the Countess of Chester Hospital between 2015 and 2018, following the conviction of neonatal nurse Lucy Letby for the murder of seven babies and the attempted murder of others.
More about this inquiry
Statutory inquiry into events at the Countess of Chester Hospital between 2015 and 2018, following the conviction of neonatal nurse Lucy Letby for the murder of seven babies and the attempted murder of others. Ordered as a non-statutory inquiry on 18 August 2023; statutory footing announced 30 August 2023 and confirmed to Parliament 4 September 2023; formally set up 19 October 2023; public hearings opened 10 September 2024 and concluded March 2025. Final report published 15 September 2026 in three volumes with 17 recommendations (Volume III, Part Three, Chapter 45). The Secretary of State for Health and Social Care made an oral statement to the Commons the same day and said the government will set out a full response.
Accepted in part · Department of Health and Social Care says in progress
Recommended
i. DHSC and NHS England must develop and put in place a barring system for all managers
(clinical and non-clinical) by September 2027. It should be reviewed in 2030 with a view
to moving to a full statutory regulation system by September 2032.
ii. NHS England must require any Trust seeking approval for the movement of a senior
manager to another Trust to demonstrate that:
a. The move is not proposed because of the manager’s lack of capability or misconduct.
b. The manager meets the fit and proper person test.
NHS England must not grant approval, and Trusts must not seek approval, unless they
are able to demonstrate the matters at a. and b. above.
iii. In addition to the statutory duty for organisations, all managers must be subject to an
individual duty of candour to all patients and colleagues. This should be included in the
code of conduct and in the contract of employment for all managers.
iv. The NHS Leadership and Management Framework Code, a code of conduct for
NHS managers published in July 2026, must be amended urgently to set out, at the
beginning, the uncontroversial duty of every manager to put patients first. I suggest
the following wording, with thanks to Mr Jarrold: ‘I will make the care and safety
of patients my first concern and act to protect them from risk.’ What matters is that
patients come first.
v. In the Leadership and Management Framework Standards, the competency ‘delivering
across healthcare’ should be first (it is currently third). The first and fundamental
competency under this heading is, rightly: “I put patients first and report safety
concerns and incidents.”
Since then (summary written by this site)
In September 2026, the Department of Health and Social Care stated that plans to regulate managers through a barring scheme for senior leaders were in progress (Department of Health and Social Care, Sep 2026). In an oral statement to the House of Commons that month, Secretary of State Yvette Cooper confirmed that the government would legislate to introduce the scheme "as soon as Parliamentary time allows" and consider expanding it further (Yvette Cooper response, Sep 2026). The record holds no update since the department's response of September 2026 (Yvette Cooper response, Sep 2026).
Addressed to Department of Health and Social Care; NHS England; NHS Trusts · Full record
The Witness Timetable states that oral evidence from witnesses on Parts A/B/C ran from 16 September 2024 to 17 January 2025. This is distinct from the 10 September opening statements.
The Inquiry held a further evidential hearing on 24 February 2025 for Dr Susan Gilby; this was after the 59 sitting days/133 witnesses stated for the Parts A/B/C hearing period ending 17 January.
Government response to the Thirlwall Inquiry (oral statement, Secretary of State for Health and Social Care)
Oral statement to the House of Commons by the Rt Hon Yvette Cooper MP, Secretary of State for Health and Social Care, delivered 15 September 2026. Verbatim opening: 'Madam Deputy Speaker, with permission, I would like to make a statement on the report of the three-year public inquiry into events at the Countess of Chester Hospital, between 2015 and 2018, led by Lady Justice Thirlwall, published today.'
Statutory inquiry into events at the Countess of Chester Hospital following conviction of Lucy Letby. Established 19 Oct 2023. Chaired by Lady Justice Thirlwall. Funded by DHSC. Hearings Sep 2024 - Jan 2025. Report expected after Easter 2026. Inquiry Legal = Counsel + Solicitor/paralegals + Experts. CP Legal = Family legal fees + non-CP legal assisting. Staff = Secretariat + Chair. Hearings = venue + AV + other. Technology = IT + Media + Office accommodation. Other = Emotional support + Publication + Admin/travel. All figures rounded to nearest £000, exclude VAT.
FY2024/25 figures re-published in FY2025/26 Inquiry report; category mapping corrected
Source and qualifications
Accounting period: 1 Apr 2024 to 31 Mar 2025.
The Inquiry FY25/26 report reproduces FY2024/25 total £13,098k. Mapped visible £000 components: secretariat 749 to staff; chair 452 to panel; counsel 1,983 plus solicitor 3,762 to inquiry legal 5,745; family legal fees 2,877 to core-participant legal; office 153 plus hearing venue 245 to accommodation 398; IT 601 plus hearing AV 1,274 to technology 1,875; experts 211, non-core-participant legal 12, emotional support 194, media 226, hearing other 344 and administration 15 to other 1,002. Safeguarding stays NULL: the source does not identify support beneficiaries for this schema. The mapped categories sum to the published £13,098k. Values are rounded to nearest £000, exclude VAT, and are not accountant-compiled accounts. Only category/source/notes fields are corrected; original period and £13,098,000 total remain.
FY2023/24 figures re-published in FY2025/26 Inquiry report; category mapping corrected
Source and qualifications
Accounting period: 4 Sep 2023 to 31 Mar 2024.
The Inquiry FY25/26 report reproduces the FY2023/24 table: total £2,834k for 4 September 2023–31 March 2024. Mapped visible components in £000: secretariat 168 to staff, chair 133 to panel, counsel 742 plus solicitor 1,397 to inquiry legal 2,139, family legal fees 216 to core-participant legal, IT 133 to technology, and emotional support 27 plus media 16 plus administration 2 to other 45. Office accommodation is a dash, so the field is NULL; safeguarding remains NULL because beneficiaries of emotional support are not specified. The rounded outer Legal costs subtotal 2,356 differs by £1k from its rounded components 742+1,397+216=2,355; component-based categories and published total are retained without inventing £1k. Source values are rounded to nearest £000, exclude VAT, and are not accountant-compiled accounts. Only category/source/notes fields are corrected; original period and £2,834,000 total remain.
Written QuestionHouse of CommonsDamian Hinds · Conservative
Asked: To ask the Secretary of State for Health and Social Care, with reference to her statement of 15 September on the Thirlwall Inquiry and the “recommendation hub to properly track our implementation progress internally, not just for this inquiry but for othe
Written QuestionHouse of LordsLord McCrea of Magherafelt and Cookstown · Democratic Unionist Party
Asked: To ask His Majesty's Government what the costs are of the (1) Hamill Inquiry, and (2) Letby Inquiry.
Answered by Cabinet Office: The Robert Hamill Inquiry opened in 2005. The previous chair of the Inquiry reported that the Terms of Reference were fulfilled in 2011. However, due to legal proceedings, the Inquiry report was only published on 14 September 2026. The total amount paid for inquiry expenses since its establishment, including expenditure since 2011, will be published by the Secretary of State …
Written QuestionHouse of CommonsKim Johnson · Labour
Asked: To ask the Secretary of State for Health and Social Care, what steps her Department are taking to improve data collection into inequalities in maternal mental health outcomes for Black women and birthing people.
Answered by Department of Health and Social Care: It is a priority for the Government to ensure that all women and babies receive the high-quality care they deserve, regardless of their background, location or ethnicity. The Department has funded the PRiSMM programme through the National Institute for Health and Care Research. It will report England-wide data on severe maternal morbidity and evaluate the Maternal Care bundle, including an …
Written QuestionHouse of CommonsMike Wood · Conservative
Asked: To ask the Secretary of State for Health and Social Care, what has been the total cost to date of the Thirlwall Inquiry.
Answered by Department of Health and Social Care: The total cost of the Thirlwall Inquiry from its commencement in September 2023 to the end of March 2026 is £18,718,000.00. This includes March 2026 forecasted amounts.
Written Ministerial StatementHouse of CommonsKarin Smyth · Labour
Statement: Ensuring strong and accountable NHS leadership will be critical to delivering our plan for change and building an NHS fit for the future.We know the important role that high quality leadership plays in fostering a compassionate and transparent culture within the NHS and we want …