Key takeaways
Act now
Many of the recommendations depend on action to be taken by others at national level, but NHS bodies should take action now.
Create a culture where concerns are heard, considered and escalated
Where deliberate harm is suspected, risk rather than proof should trigger safeguarding action and appropriate external escalation.
Strengthen leadership and organisational learning
Boards and senior management must take active ownership of patient safety.
The publication of the Thirlwall inquiry report should prompt health and social care organisations and their leaders to consider whether their governance, culture and safety arrangements are capable of identifying concerns early and responding effectively.
The Report's message is straightforward. Concerns must be raised, heard and acted upon promptly, and patient safety must take precedence over any reputational or professional interests.
While many of the inquiry's recommendations require action by national bodies such as the Department of Health and Social Care and NHS England, organisations do not need to wait for wider reform before taking action. There are practical steps senior leaders can take now to strengthen their organisation’s oversight, improve safeguarding arrangements, particularly those involving investigations into the death of a child or deliberate harm, support staff who speak up to raise concerns and ensure those concerns are escalated to the most appropriate agency without delay.
What leaders should do now
Strengthen Board oversight
One of the clearest lessons from the inquiry is that concerns can be missed even where information is available. The issue is often not a lack of data, but a failure to bring information together, recognise patterns and act on warning signs. The inquiry specifically identified the need for stronger Board oversight of mortality data and clearer escalation pathways for concerning trends.
The inquiry’s recommendation six states that by 31 March 2027 all hospital trusts must have in place:
Effective mechanisms for Board-level monitoring of all deaths of children and babies.
A clear and predetermined route to senior management for the escalation of concerning data trends or patterns.
Action: Boards should review now whether they have effective mechanisms for Board-level monitoring of all deaths of children and babies and a clear, predetermined route for escalating concerning data trends or patterns to senior management so that they can meet the deadline for implementation of that recommendation.
Insulin access and storage
The inquiry identified serious concerns around access to and storage of insulin. Organisations should not assume that existing arrangements remain appropriate simply because no concerns have previously arisen.
Action: Review who can access insulin, how access is monitored and whether current controls are proportionate to the risks involved. To comply with the inquiry’s recommendation two, 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. The recommendation also states that each trust should install CCTV cameras focussed on storage fridges, cupboards or units and store recordings for at least 28 days.
Review speaking up arrangements
The inquiry acknowledged that concerns are often identified by staff long before they reach senior leaders.
Action: Review Freedom to Speak Up arrangements and test whether they work in practice. How is the Board assured of their effectiveness? The key question is not whether the policy exists, but whether staff have confidence that concerns will be listened to, investigated and acted upon.
Leadership accountability
The inquiry reinforced the importance of leadership when complex and challenging patient safety concerns arise.
Action: Ensure senior leaders receive training in patient safety, safeguarding including processes following a death of a child and those where there is a suspicion of deliberate harm within and outside of the organisation, risk management and duty of candour.
Review safeguarding policies and processes
The inquiry examined how concerns involving members of staff can sometimes sit uneasily between safeguarding, HR and governance processes.
Action: The Board and all relevant staff of hospitals with neonatal units must be informed that the Sudden Unexpected Death In Childhood (“SUDIC”) process applies to the sudden and unexpected death of babies who have never left hospital. The Department of Health and Social Care is required by the Inquiry’s recommendations to ensure revised SUDIC guidelines are distributed to all trusts by 31 March 2027.
Organisations can expect requests for information from regulators and national bodies. To prepare:
Ensure you can evidence that the Board and all relevant staff within neonatal units have been informed that the SUDIC process applies to the sudden and unexpected death of babies who have never left hospital.
Review safeguarding policies to ensure they clearly address concerns involving staff members, including concerns about deliberate harm both within and outside the organisation.
Ensure escalation pathways are understood across clinical, safeguarding, HR, legal and executive teams and supported by regular training.
Improve data and early warning systems
A recurring theme throughout the inquiry was the failure to identify concerning patterns at an early stage and the risk that looking at incidents in isolation can mean wider risks are not identified.
Action:
Review whether governance and reporting arrangements enable unusual trends, incidents and patient safety concerns to be identified and escalated quickly. Responsibility for reviewing and reporting key safety data should be clearly allocated.
The inquiry’s recommendation seven states that all hospitals with a neonatal unit should name a ‘lead reporter’ with responsibility for inputting data at least weekly and reviewing real time data in the MBRRACE system. The lead reporter should report to the Board.
Support patients and families
Throughout the Inquiry, it was highlighted that families are an important source of information and may identify concerns, inconsistencies or questions that organisations have overlooked. Appropriate communication and engagement with families is vital, as is the offer of support following a patient safety incident or death. One of the inquiry’s recommendations is that the National Bereavement Care Pathway for neonatal death is implemented in all Trusts by 31 August 2027.
Action:
Review bereavement support, communication processes and duty of candour arrangements to ensure families receive timely information, appropriate support and clear explanations when concerns arise.
Implement the National Bereavement Care Pathway for neonatal death by 31 August 2027.
Encourage professional curiosity and challenge
The inquiry was clear that patient safety can be compromised when assumptions are not challenged or when staff feel unable to question decisions made by colleagues or senior leaders.
Action: Create an environment in which constructive challenge is expected rather than discouraged. Leaders should actively seek assurance that concerns have been explored thoroughly and have been properly scrutinised.
Document concerns and decisions
Many inquiries including Thirlwall reveal difficulties in understanding what concerns were raised, who knew about them and why particular decisions were made.
Action: Review how concerns, escalation decisions and risk assessments are recorded. Where decisions are made not to escalate an issue or pursue a concern further, ensure the rationale is documented clearly and is capable of later scrutiny.
Internal investigation and criminal investigation
A key theme running through the inquiry was that health and social care organisations are not responsible for determining whether criminal conduct has occurred. That is the role of the police and criminal justice agencies. Waiting for certainty before taking action can delay important safeguarding interventions.
Action: Ensure staff understand that safeguarding action is triggered by risk, not proof. Where concerns give rise to a suspicion of deliberate harm, organisations should escalate promptly and involve the appropriate external agencies, including the police. Suspicion is enough.
Further action will need to be taken once the proposed Suspicion of Deliberate Harm Protocol (recommended by the inquiry) and associated guidance is produced and disseminated.
Accountability for managers
Following the themes set out in the proposed new Hillsborough law, the inquiry recommends strengthening individual accountability for managers through a proposed individual duty of candour.
Action:
Non-clinical managers should understand the requirement to be open and honest with patients, families and colleagues, respond appropriately to concerns and support a culture where staff feel able to speak up.
Employment contracts, job descriptions and appraisal processes should be reviewed to ensure these expectations are clearly set out and reflected in behaviours.
What happens next?
Much of the focus will now turn to the implementation of the inquiry's recommendations and the national response from government, regulators and health and social care bodies.
For Boards and senior leaders in the health and social care sector, the immediate question is what lessons can they learn now? The organisations that will learn most from the inquiry are those that examine their own systems critically and make changes before problems emerge. Ultimately, the most effective response to Thirlwall will be a culture in which concerns about patient safety are identified early, escalated to the appropriate agencies and acted upon without delay.
Contact us today to discuss how members of our public inquiries team can support you in assessing your governance, culture and safety arrangements in the aftermath of the report’s publication.
