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Thirlwall Inquiry: Final Report and Recommendations
15 September 2026
Lead MP
Yvette Cooper
Normanton, Pontefract and Castleford
Lab
Debate Type
Ministerial Statement
Tags
EmploymentNHS
Other Contributors: 11
At a Glance
Yvette Cooper raised concerns about thirlwall inquiry: final report and recommendations in the House of Commons. A government minister responded. Other MPs also contributed.
How the Debate Unfolded
MPs spoke in turn to share their views and ask questions. Here's what each person said:
Government Statement
Minister Cooper apologised for the timing and thanked the Opposition for their understanding. She began by addressing the report of the three-year public inquiry led by Lady Justice Thirlwall into events at the Countess of Chester hospital between 2015 and 2018. The inquiry focused on the experiences of 13 families who lost their newborn babies or who saw them experience serious collapse or injury. Cooper expressed deep sorrow for the distress and loss endured by these families and recognised the thoroughness and devastating nature of the report. She highlighted that the inquiry identified multiple and repeated mistakes and failings by organisations and individuals, and found failures in safeguarding, governance, regulation, and candour. The report concluded that some babies would have been saved if action was taken earlier. Cooper committed the Government to act on the recommendations and reiterated the importance of safeguarding, safety, and respect for families in the NHS. She outlined specific actions such as compulsory safeguarding training, new protocols, and employment requirements, as well as the introduction of video baby monitors and the update of sudden unexpected death in infancy and childhood guidance. The Government also agreed to legislate for a barring scheme for senior leaders and managers and to bring forward amendments for a new maternity and neonatal commissioner. Cooper concluded by emphasising the need to prioritise safety and safeguarding for babies in the NHS.
Damian Hinds
Con
East Hampshire
Question
When does the Secretary of State anticipate the Government's full response to the report will be published?
Minister reply
The Government will consider the entire report and set out a full response in due course.
Damian Hinds
Con
East Hampshire
Question
What measures will be taken to establish independent escalation pathways outside the management hierarchy?
Minister reply
The Government will review the existing 'freedom to speak up' system and the National Guardian's Office to ensure independent escalation pathways are in place.
Damian Hinds
Con
East Hampshire
Question
Will the Secretary of State reconsider the proposal to end the Health Services Safety Investigations Body?
Minister reply
The Government will consider the proposal but also the role of the Health Services Safety Investigations Body in safeguarding and patient safety.
Damian Hinds
Con
East Hampshire
Question
How close is the near real-time process to being fully real-time and automated?
Minister reply
The Government is committed to real-time reporting and automated analysis to identify abnormalities and trigger independent external review, but the specifics of the timeline and implementation are under review.
Damian Hinds
Con
East Hampshire
Question
What is the initial assessment of how the use of cameras in cots can be achieved and by when?
Minister reply
The Government will set out a roadmap for the introduction of video baby monitors, with a commitment to implement them to help parents feel better connected to their babies.
Damian Hinds
Con
East Hampshire
Question
Is an internal hub sufficient to ensure recommendations from previous inquiries are pursued?
Minister reply
The Government is setting up a recommendation hub to track implementation progress internally, but will also work with the National Audit Office and Parliament to ensure recommendations are pursued.
Damian Hinds
Con
East Hampshire
Question
Damian Hinds thanked the Secretary of State and welcomed the report, expressing the need for reliable guards against such tragedies. He asked when the full response would be published and questioned the removal of the freedom to speak up system and the abolishment of the National Guardian's Office and HSSIB. He inquired about the real-time reporting systems and the implementation of recommendation 1 on remote monitoring. He proposed the formation of a Joint Committee of Parliament and the role of the National Audit Office in ensuring recommendations are pursued.
Minister reply
Yvette Cooper thanked Damian Hinds for his questions and emphasised the importance of whistleblowing and leadership responsibility. She stated that the full response would be published within six months. She discussed the intention to transfer HSSIB into the Care Quality Commission to ensure the independent role and investigations continue. She mentioned the new systems in place for real-time safety alerts and the need for interoperable data systems. She proposed the creation of a hub for health inquiry recommendations to ensure the implementation of past reports.
Samantha Dixon
Lab
Bolton South East
Question
Dixon raises the issue of a national oversight mechanism to ensure that recommendations from important public inquiries are carried forward and never forgotten, questioning if the Secretary of State will support this essential recommendation beyond the NHS to all inquiries.
Minister reply
Yvette Cooper acknowledges the importance of the duty of candour and the need to ensure that boards follow this duty. She commits to discussing with the Cabinet Office the establishment of a national oversight mechanism and highlights the intention for HSSIB to continue as part of the CQC.
Helen Morgan
Lab
Hon Aberconwy
Question
Morgan expresses her support for the duty of candour for management and highlights the importance of stronger whistleblowing mechanisms, including her amendments to the Health Bill to protect patient safety and prevent the abolition of HSSIB and the National Guardian’s Office.
Minister reply
Yvette Cooper agrees that HSSIB’s role needs to continue and commits to looking again at the arrangements to ensure they meet the expectations of the inquiry’s report. She emphasises the need to put patient safety first and to make sure that maternity and neonatal care are central to the NHS.
Scott Arthur
Con
Wyre and Preston North
Question
Arthur asks for a commitment to addressing the problem of an overreaction to blame culture, which has held some managers back from confronting bad behaviours, and for a timeline for the implementation of all the recommendations.
Minister reply
Yvette Cooper highlights the need to be prepared to think the unthinkable when it comes to staff member harm and the importance of taking safeguarding action when there is a concern or a suspicion. She commits to addressing the challenges around culture, concerns about blame, and the confidence and support needed to speak out.
Shadow Comment
Damian Hinds
Shadow Comment
Shadow Minister Hinds thanked the Secretary of State for the statement and Lady Justice Thirlwall and her team for their work. He highlighted that the report is thorough and devastating, revealing recurring themes of the dismissal or undermining of whistleblowers and concerns about institutional reputation hampering patient safety. Hinds questioned the timeline for the Government's full response to the report and inquired about the existing freedom to speak up system and the need for a national oversight body. He also raised concerns about the abolition of the Health Services Safety Investigations Body and the need for real-time reporting and automated analysis to identify abnormalities. Hinds asked about the use of cameras in cots and the timeline for their implementation. He expressed concern about the non-implementation of previous recommendations and suggested that a Joint Committee of Parliament or the National Audit Office should ensure recommendations are pursued.
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