The Thirlwall Inquiry: What NHS Boards, Leaders and Healthcare Organisations Must Do Next

By Stuart Marchant, Partner, Bevan Brittan LLP, who acted as the Recognised Legal Representative for the Royal College of Paediatrics and Child Health in the Inquiry.

The publication of the final report of the Thirlwall Inquiry represents one of the most significant moments in NHS governance and patient safety in recent years.

Established to examine the circumstances surrounding events at the Countess of Chester Hospital following the conviction of former neonatal nurse Lucy Letby, the Inquiry has looked well beyond the actions of an individual. Its focus has been on the organisational, cultural and governance factors that contributed to failures in recognising, escalating, and responding to concerns.

The implications extend far beyond a single trust. NHS boards, integrated care systems, regulators, and healthcare leaders across the country will be examining the report in detail, not simply to understand what happened, but to consider what steps are necessary to prevent similar failures occurring elsewhere.

At its heart, the Inquiry poses a fundamental question: how can healthcare organisations ensure that concerns are identified early, heard appropriately, and acted upon decisively to protect patients from harm?

More than a review of individual conduct

While the criminal acts committed by Lucy Letby formed the backdrop to the Inquiry, its remit was considerably broader. The Chair examined clinical and managerial decision-making, organisational responses to concerns, governance arrangements, regulatory oversight, and aspects of NHS culture that may have contributed to opportunities being missed.

The report identifies failures in management, governance, and safeguarding, together with shortcomings in the escalation and investigation of concerns. Importantly, it explores whether opportunities existed to intervene earlier and whether a different organisational response might have reduced the risk of further harm.

For healthcare providers, the message is clear. Patient safety cannot depend solely upon the vigilance of individuals. It requires effective systems, strong governance structures and organisational cultures that support challenge, scrutiny, and accountability.

Governance and board oversight in focus

One of the most significant themes emerging from the Inquiry is the responsibility of boards and senior leaders to understand and respond to emerging patient safety risks.

The Inquiry reinforces the expectation that boards must be able to demonstrate effective assurance arrangements and provide constructive challenge where concerns are raised. Information relating to patient safety must not simply be reported; it must be actively scrutinised, understood and acted upon.

Boards may wish to consider:

• How effectively concerns are escalated throughout the organisation

• Whether early warning signs can be identified through existing assurance mechanisms

• Whether patient safety information presented to the board provides sufficient insight and challenge

• Whether investigations and decision-making processes are sufficiently robust and independent

• Whether there is clear accountability for responding to significant concerns

These questions are not new, but the Inquiry has given them renewed urgency.

Culture, speaking up and psychological safety

A recurring theme throughout the evidence was the experience of clinicians who raised concerns and their perception of how those concerns were received.

For many organisations, this aspect of the report may prove particularly significant. The effectiveness of governance arrangements is closely linked to organisational culture. Systems can only work if individuals feel able to use them.

A positive patient safety culture requires staff at every level to feel confident that concerns will be listened to, investigated and addressed fairly. Equally, organisations must ensure that concerns can move quickly through governance structures where patient safety issues are identified.

Many NHS organisations have invested heavily in Freedom to Speak Up arrangements and wider cultural improvement initiatives. The Inquiry provides an opportunity to test whether those arrangements are delivering the intended outcomes in practice rather than merely operating as a compliance exercise.

Managing concerns about individuals

The report also highlights the complexity of responding to concerns about individual employees, particularly where allegations are serious, but evidence is contested or investigations remain ongoing.

Healthcare organisations must navigate a difficult balance between protecting patients and respecting employment rights, procedural fairness, and professional regulation.

The Inquiry is likely to prompt many employers to review their policies governing suspension, redeployment, escalation, safeguarding referrals, and decision-making responsibilities. Organisations may wish to consider whether existing processes enable precautionary action to be taken swiftly where patient safety concerns arise.

Safeguarding and patient safety governance

Perhaps the most important lesson from the Inquiry is the need for organisations to recognise patterns of concern rather than viewing incidents in isolation.

Effective patient safety governance depends upon the ability to identify trends, connect information from different sources and ensure concerns are escalated to those with the authority to act.

As organisations reflect on the report, many are likely to review:

• Patient safety reporting systems

• Safeguarding arrangements

• Governance and assurance frameworks

• Incident investigation processes

• Board reporting and escalation mechanisms

• Training and development for managers and senior leaders

Stakeholders, regulators, patients, and the public will expect healthcare organisations not only to understand the Inquiry's findings but also to demonstrate how lessons have been translated into meaningful action.

Looking ahead

The Thirlwall Inquiry is likely to become a defining reference point in discussions about patient safety, healthcare governance, and organisational accountability for many years to come.

For NHS boards and leaders, the report presents both a challenge and an opportunity: a challenge to examine critically whether existing arrangements are sufficiently effective, and an opportunity to strengthen systems, culture, and leadership in support of safer care.

While the circumstances considered by the Inquiry were exceptional, the themes it explores are universal. Every healthcare organisation must ensure that concerns can be raised, heard, investigated, and addressed before harm occurs.

The real test will not be whether organisations read the report, but whether they act upon it. Those that engage proactively with its lessons will be best placed to strengthen public confidence, support their workforce, and deliver safer care for patients.

Source: The Thirlwall Inquiry | Examining 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.

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