Thirlwall Inquiry

i. All Trusts must provide safeguarding training to all staff (appropriate to their role and expertise) and Board members, including Non-Executive Directors. This training should include how to deal with concerns and suspicions about deliberate harm caused by staff. ii. By March 2027, every existing contract of employment for work in an NHS hospital must be amended to include an obligation on the employee to follow all relevant safeguarding guidance, including the Suspicion of Deliberate Harm Protocol (at Recommendation 9), for dealing with concerns and suspicions about deliberate harm. Agency and bank staff contracts and all new contracts of employment must include the same obligation.

The Secretary of State for Health and Social Care, Yvette Cooper, stated in September 2026 that the recommendation was under consideration, noting that an urgent review of the NHS safeguarding framework and training had been requested (Yvette Cooper response, Sep 2026). In the same month, Duncan Burton, Chief Nursing Officer for England, and Sarah-Jane Marsh, NHS England Chief Operating Officer, directed trusts and integrated care boards to ensure staff and board members comply with safeguarding training requirements and understand how to escalate concerns (Duncan Burton; Sarah-Jane Marsh, Sep 2026).

NHS England must provide, by 31 March 2027, a clear and timed route to ensuring that computer systems are harmonised across the NHS by December 2028. Work on the development of a mandatory information standard with requirements for interoperability between systems should be taken forward and implemented as soon as possible. This should mean that data relating to babies and neonates in hospital may be entered on a single occasion, be reviewed in a timely manner and facilitate continuous monitoring.1

In an oral statement to the House of Commons in September 2026, Yvette Cooper, Secretary of State for Health and Social Care, stated that the government had implemented the maternity outcome signal system to provide near real-time safety alerts and acknowledged regarding technology recommendations that "we must do more" (Yvette Cooper response, Sep 2026). The record holds no update since the Department of Health and Social Care's response of September 2026 (Yvette Cooper response, Sep 2026).

i. All hospitals with a neonatal unit should name a ‘lead reporter’ with responsibility for inputting data regularly (at least weekly) and reviewing real-time data viewers on neonatal and maternity units in the MBRRACE system. Whilst the lead reporter does not necessarily need to be a clinician, they must be trained to understand and interpret the available data and able to explain and discuss it with clinicians. ii. Save where data requires immediate action, in which case a report should be made to the Medical Director and the Board immediately, the lead reporter should report to Trust Boards at least every six months and advise: a. whether any alerts or a need for investigation have arisen b. the investigation or action plan in place.

In an oral statement to the House of Commons in September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, stated that the government has implemented the maternity outcome signal system to provide near real-time safety alerts, but agreed regarding technology recommendations that "we must do more" (Yvette Cooper response, Sep 2026). The record holds no update since the department's response of September 2026 (Yvette Cooper response, Sep 2026).

Protocol i. By 31 March 2027, NHS England must produce and distribute a one-page protocol setting out the steps to be taken by managers when concerns or suspicions are raised that a healthcare professional may have deliberately harmed a patient. The Suspicion of Deliberate Harm Protocol must make explicit that: a. It is irrelevant whether the person to whom the concerns have been expressed does or does not believe they are true, as is the fact that the person raising the concern is not sure. b. Where concerns or suspicions of deliberate harm are being raised in good faith, they must be acted upon immediately. c. Only in cases where the concerns are obviously irrational or malicious (which assessment must be recorded) will no further action be justified. d. Pending investigation of a member of staff, action to protect patients by moving the person suspected of causing harm is likely to be the first step. e. The moving of a person suspected of causing harm and the investigation into suspicions and concerns about a member of staff is a neutral act. f. Safeguarding steps must be followed, as a result of which the police will become involved. Guidance ii. Guidance of no more than two pages should accompany the protocol. It must set out the factors to be considered when assessing the nature of the concerns and suspicions. The reader should be directed to guard against their own biases, loyalties and prejudices. The guidance should explain what should be said and when to those who are or who may be involved with any investigation (such as patients, parents and staff). This must include that patient safety comes first, and investigation is required. The guidance should also explain that failure to follow the protocol will be a breach of contract by an employee, as well as a breach of the relevant code of conduct. Implementation iii. Trusts must embed the Suspicion of Deliberate Harm Protocol and guidance within their hospital.

In September 2026, Yvette Cooper, Secretary of State for Health and Social Care, addressed safeguarding recommendations including a new protocol, stating that she had asked the Chief Nursing Officer to urgently review the NHS safeguarding framework and training (Yvette Cooper response, Sep 2026). The Minister noted that although a revised safeguarding framework was published in April 2026, further urgent examination was required in light of the report (Yvette Cooper response, Sep 2026). The record holds no update since the Department of Health and Social Care's response of September 2026 (Yvette Cooper response, Sep 2026).

i. The National Medical Examiner should, by 31 March 2027, prepare and distribute a one-page document setting out all the steps to be taken by a medical examiner when dealing with the death of a neonate. ii. The revised SUDIC guidelines (see Recommendation 8 above) should be set out within the good practice guidelines for medical examiners, not merely signposted. iii. Medical examiners should ask direct questions of the attending practitioner as to whether there is a concern that a child has been harmed or some other safeguarding concern. Where there may be such a concern, the medical examiner should ensure that there is a record made that day of the contact details of every doctor or nurse who attended to the baby during life. iv. There should be a pool of neonatologists who can assist medical examiners with their work until such time as it is possible to appoint the appropriate number of regional neonatologist medical examiners. Ring-fenced funding should be provided for this purpose. v. The medical examiner system should be reviewed again in 2027 by DHSC. The review should include the adequacy of funding for medical examiners and their support staff and offices. In particular, the question of whether the funding should be ring-fenced must be addressed. Thereafter, reviews should be as directed by DHSC and NHS England.

In September 2026, the Department of Health and Social Care stated that it had begun work on "strengthened guidance for medical examiners reviewing neonatal deaths" while considering the inquiry's recommendations in full (Department of Health and Social Care, Sep 2026). In an oral statement that same month, Yvette Cooper, the Secretary of State, confirmed that the government would set out further plans to strengthen neonatal expertise when publishing its full response (Yvette Cooper response, Sep 2026). The record holds no update since the department's response of September 2026 (Yvette Cooper response, Sep 2026).

i. CQC should conduct without-notice inspections of hospital departments. Inspection teams should include at least two current practising experts in the relevant field (in this case paediatrics/neonatology). ii. Inspectors should investigate what is happening in hospital departments and not accept what they are told at face value. Where processes are being inspected, questions must be asked to elicit the effectiveness of those processes.3 iii. Training should make explicit that CQC is responsible for ensuring the safety of patients in hospitals and not just for checking there are processes in place which, if implemented, should ensure patient safety. Inspectors and team leaders must always approach an inspection of neonatal services not as a box-ticking exercise but as a way to determine that babies in hospital are safe.

In September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, stated to the House of Commons that the government would ensure recommendations for regulators, including the Care Quality Commission, are "taken seriously", adding that while the maternity outcome signal system had been implemented, it agreed more must be done (Yvette Cooper response, Sep 2026). The record holds no update since the department's response of September 2026 (Yvette Cooper response, Sep 2026).

A new responsibility for auditing the implementation of the recommendations of statutory inquiries into NHS bodies should be given to the National Audit Office. Funding for appropriate additional staffing should be made available so that it may begin its work by September 2027.

The Inquiry recommended that the National Audit Office audit recommendations from statutory health inquiries. In September 2026, Yvette Cooper, Secretary of State for Health and Social Care, stated that her department is setting up a recommendation hub to track progress internally across the National Health Service (NHS) (Yvette Cooper response, Sep 2026). She stated that the department will work with the Cabinet Office on improvements in this area to respond to the inquiry (Yvette Cooper response, Sep 2026). The record holds nothing dated later than the response of September 2026 (Yvette Cooper response, Sep 2026).