30 Inquiries in 30 years examined

The Inquiry has published a Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues, which will inform Part C of the Inquiry’s investigative phase.  

The Table collates recommendations from thirty inquiries over the course of thirty years that have taken place in England & Wales and which relate to events in hospitals and other healthcare settings, or safeguarding of vulnerable individuals. This document details the extent to which these recommendations have been implemented in order to explore whether they have made a difference. 

This Review of Recommendations is also 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?” 

The Inquiry has also commissioned two other reports to shed light into the effectiveness of NHS management and governance structures and processes, external scrutiny and professional regulation and consideration of NHS culture.  

The document is available here: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues 

The Inquiry intends to call experts to give further evidence in due course. 


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. 
  • Key documents, including the Inquiry’s Terms of Reference and List of Questions are available here
  • The Inquiry held its first preliminary hearing on 16 May 2024 in Chester.