Change in the culture of NHS neonatal care ‘must start now’, says Chair as she announces evidence-gathering work with midwives, doctors, nurses and hospitals

Read the transcript Lady Justice Thirlwall’s address

The Appeal Court judge leading the public inquiry into the events at the Countess of Chester Hospital, and the implications of those events, today said real change in the culture of NHS neonatal care must start now.

Announcing the inquiry work programme online this morning, Lady Justice Thirlwall committed to investigating the issues “from the ward to the boardroom”.

The Thirlwall Inquiry was set up on 19 October 2023 to investigate the 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.

In a recorded address marking the start of the Inquiry’s work, Lady Justice Thirlwall said:

“The parents of the babies who were murdered or suffered injuries, some life-long, live with the consequences every day. On top of their grievous loss, they endured years of uncertainty about what had caused death or injury. For some, uncertainty remains.

“All have made it plain to me that they want to do all they can to make sure no one else suffers as they do.  I, too, with the help of the inquiry team and many others, will do all I can to make sure that no one else suffers as they have. It is unconscionable that this situation would ever occur again.”

She added:

“What happened to these babies and their families is indescribable.   I know that many professionals (clinical and otherwise) are already implementing changes identified as necessary before this Inquiry began.  I expect to learn whether these changes are effective in preventing harm. I ’d like to emphasise the importance of everyone thinking about the issues in real time, identifying improvements, implementing them and then assessing their impact.  This way, the inquiry facilitates improvement in the here and now rather than waiting for the report.”

Speaking on the inquiry website, the Chair set out a timeline ahead of the Inquiry’s first hearings, which are currently planned for autumn 2024 and will take place in Chester.

She outlined the rigorous evidence gathering that the Inquiry team is already undertaking and urged all doctors, nurses, midwives and managers in hospitals with neonatal to complete an anonymous survey seeking their views on the culture on neonatal units. 

A separate questionnaire has been sent to every hospital in England with a neonatal unit. This is to be completed by both the Medical Director and a senior non-clinical manager at each hospital.

The Chair also announced that the Inquiry will hear from expert witnesses, details of which will appear on the website in due course.