The report calls for careful, evidence-based reflection on governance, leadership, safeguarding and the escalation of concerns. Our forthcoming webinar will examine what the findings mean in practice.
The Thirlwall Inquiry, set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital, published its final report and recommendations on 15 September 2026.
The level of public interest and emotive reporting throughout the Inquiry has been high. As such the report is careful to preface its recommendations by stating that it is not “a recitation of all the evidence” and that findings have been made “about what happened at the Countess of Chester Hospital (the Countess) from 2015 to 2018 on the balance of probabilities, having considered the evidence and the submissions made on behalf of all Core Participants.”
However, patients, families, the wider public and, of course, NHS institutions and professionals will be keenly aware of the importance of the report’s recommendations. The effect of which goes beyond mere updates to internal control, procedure and convention but reach further into public trust and confidence; after all the NHS cares for us all at the most vulnerable times in our lives.
The immediate task for organisations is not to rush towards generic assurances or treat the report as relevant only to neonatal services. Boards should consider their findings carefully, consider culture and process, identify which recommendations and lessons apply to their organisation, and test the evidence underpinning current assurance.
The five questions below provide a practical starting point for boards, executives and governance professionals.
1. Have we considered the report, its recommendations and our organisational position?
Before turning to specific assurance themes, boards should first be clear that the report and its recommendations have been received, understood and assessed for relevance to their organisation. This should include an honest assessment of current position, applicable learning, existing controls and any areas requiring further evidence or action. In doing so, the Board should be mindful to the additional questions below.
2. Can the board see emerging risk clearly enough?
Boards depend on the quality, completeness and presentation of the information that reaches them to make the best decisions possible.
Boards should therefore consider whether intelligence from clinical incidents, mortality, safeguarding, workforce issues, complaints, claims and speaking-up routes is brought together in a meaningful way. This relies on robust data quality, integrity, comparison and narrative, and whether trends or departures from usual presentation or procedure are clearly identified. As well as triangulating this data and understanding with patient experience.
3. Do escalation, challenge and accountability work in practice?
Governance works best when concerns can be raised, tested and resolved through clear routes. Organisations should examine whether staff understand how to escalate concerns, whether those concerns can move effectively across professional and managerial boundaries, and what happens when views differ or issues remain unresolved.
That review should also consider culture. It is not enough for a board to know that policies, guardians and reporting channels exist; it needs assurance that staff feel able to use them, that challenge is welcomed rather than suppressed, and that those who raise concerns are kept informed about how they have been considered.
4. Are records complete enough to support scrutiny and learning?
The Inquiry also underlines the importance of a reliable evidence trail. Contemporaneous notes, clinical and nursing records, later reviews and formal minutes can all become critical in understanding what happened, what was known, what was decided and why.
Boards should therefore test whether material meetings and decisions are properly documented, whether informal notes are captured where no formal minutes are taken, and whether records are sufficiently complete, accurate and accessible to support later scrutiny while respecting confidentiality and privacy.
5. Can the organisation demonstrate learning?
Learning should then be translated into proportionate action where needed, with clear ownership, timescales and evidence requirements. Completion of an action is not the same as evidence of improvement. Closure criteria should therefore include testing, audit or other evidence that the intended change has occurred and is sustained.
So how do we test this?
A practical starting point
The board should ensure that they have received the Thirwall inquiry report itself and recommendations, with detailed review delegated to an appropriate sub-committee. This should be followed by a structured review of assurance processes, current controls, supporting evidence, gaps, accountable owners and the route by which the board will receive assurance.
A proportionate organisational response
A proportionate response should be tailored to the organisation and its services. It may include a board seminar, an executive-led applicability assessment, targeted deep dives, a review of escalation and speaking-up arrangements, and a clear audit trail linking the report to decisions and actions.
The response should also connect with existing patient safety, safeguarding, quality governance and workforce work. Creating a separate programme without those links risks fragmentation and duplicated assurance.
Join our forthcoming webinar
We will be hosting a webinar examining the governance, leadership and operational assurance implications of the Thirlwall Inquiry Report. The session will focus on practical steps for boards, executives, non-executive directors, governance professionals and clinical leaders. Join our mailing list to register your interest and receive the webinar invitation when further details are available.
How we can help
Our healthcare team can support NHS organisations in developing a proportionate, evidence-based response to the report, including:
- board and executive briefings and training
- structured applicability and gap assessments
- reviews of escalation, speaking-up and safeguarding governance
- board assurance and committee effectiveness reviews
- board paper reviews and training
- governance reviews;action tracking and evidence frameworks
- support with investigations, public inquiries, inquests, regulatory scrutiny and wider organisational learning.
The publication of the report is the beginning of the organisational response, not its conclusion. Boards now need to turn evidenced reflection into a clear and tested programme of assurance and improvement; which in turn is delivered and reported on.
Useful links
Thirlwall Inquiry report – Final report and recommendations published 15 September 2026.
The Thirlwall Inquiry report page – Official Inquiry report and supporting materials.
Full Inquiry website: https://thirlwall.public-inquiry.uk/
Key Contacts
Audio versions of this article are autogenerated and occasional errors in interpretation may be made. The content of this article is for general information only. It is not, and should not be taken as, legal advice. If you require any further information in relation to this article, please contact the author in the first instance. Law covered as at October 2026.