Counsel to the Inquiry gives a procedural update, including announcing venue and substantive hearing dates.

Attendees at the Thirlwall Inquiry’s Preliminary Hearing in Chester heard Counsel to the Inquiry, Rachel Langdale KC, give a procedural update on Lady Justice Thirlwall’s investigation into the events at the Countess of Chester Hospital.

It was announced that the Inquiry will begin its substantive hearings on 10 September 2024, with opening statements. These will be heard from both Counsel to the Inquiry and from legal representatives of Core Participants. The proceedings will take place at the Inquiry’s venue in Liverpool Town Hall.

In preparation for the substantive hearings, the Inquiry has sent out over 180 Rule 9 requests to witnesses whose evidence relates to Part B of the Terms of Reference. Midwives, nurses, doctors, managers, former board members and non-executive directors and those involved in external reviews have been asked to reflect on the events at the Countess of Chester Hospital.

Expert witnesses instructed

Lady Justice Thirlwall has appointed two expert witnesses to assist with aspects of the investigation on Part C of the Inquiry’s Terms of Reference.

Professor Mary Dixon-Woods has been instructed to report on cultural issues in the NHS, in particular what represents a healthy culture, her views on safety issues and expected standards for openness, transparency and candour. She is the Director of THIS Institute, and the Health Foundation Professor of Healthcare Improvement Studies in the Department of Public Health and Primary Care at the University of Cambridge.

Sir Robert Francis KC’s instructions relate to, amongst other things, the implementation of recommendations made by previous reviews and inquiries into NHS patient care. He is a barrister and expert in medical law. Sir Robert was the Chair of the Mid Staffordshire NHS Foundation Trust Public Inquiry and has been involved in several investigations and inquiries into NHS care and patient safety.

The Chair also intends to instruct Professor John Bowers, an expert in employment law, on issues relating to the whistleblowing, disciplinary and grievance procedures at the Countess of Chester Hospital.

Review of previous recommendations published

The Inquiry has today published a table of the implementation of recommendations from a number of previous inquiries into healthcare issues.  The table will inform Part C of the Inquiry’s Terms of Reference,  The table has now been uploaded to the website.

The table collates recommendations from thirty inquiries over the course of over thirty years that have taken place in England & Wales. The table details the extent to which these recommendations have been implemented in order to explore whether they have made a difference.

This table develops one of the commitments the Chair, Lady Justice Thirlwall, made at the launch of the Inquiry. In a video address, she said:

“We all know that there have been many inquiries into events in hospitals and other health care settings over the last thirty years.” She added: “I want to know what recommendations were made in all these inquiries, I want to know whether they were implemented. What difference did they make? Where does accountability lie for errors that are made?”

Inquiry investigating NHS culture

The Inquiry has commissioned two reports shedding light onto the effectiveness of NHS management, governance structures and processes, external scrutiny, professional regulation and NHS culture.

A survey, delivered by the charity Picker, was sent to over 120 NHS trusts and received over 7,500 responses. Its purpose was to obtain insights into the working relationships between professionals in neonatal units, including senior managers, and to hear views about the culture of each unit.

A detailed questionnaire was also issued to every hospital in England with a neonatal unit, to be completed by both the Medical Director and a senior non-clinical manager. The Nuffield Trust is assisting the Inquiry team in reviewing and analysing the completed questionnaires.  This will provide the Inquiry with an understanding of governance and accountability policies, culture issues, and staffing and working relationships between and across professionals.  The analysis will also look at the reporting and managing of concerns, support for the bereaved, and current practice and procedures in neo-natal units to keep babies safe.


Notes to editors:

  • The Thirlwall Inquiry has been 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.
  • An expert witness  is an individual who is asked to give an opinion on matters which call for their particular expert skill and knowledge. An expert is not a witness of fact. Their role is to provide expertise on their specialist area, which will assist the Inquiry in delivering its Terms of Reference. 
  • Key documents, including the Inquiry’s Terms of Reference and List of Questions are available here.
  • Reporting restrictions apply. Please also see the Inquiry’s Restriction Order Protocol for more information.