The leading baby loss charity Sands has urged immediate action following the findings of the Thirlwall Inquiry, warning that wider systemic failures in maternity and neonatal care must be addressed to prevent avoidable harm.
The Report of the Public Inquiry into events at the Countess of Chester Hospital, chaired by Lady Justice Thirlwall, was published on 15th September 2026. It examined events at the hospital between 2015 and 2018 following the convictions of former neonatal nurse Lucy Letby for the murder of seven babies and the attempted murder of seven others. The inquiry found profound failures in management, governance, and safeguarding, and concluded that some babies could have been saved if action had been taken earlier.
The inquiry found profound failures in management, governance, and safeguarding at the Countess of Chester, including a complete failure to protect babies on the neonatal unit. Opportunities to protect babies were missed when concerns raised by senior doctors were not properly acted upon, while the inquiry found that staff failed to recognise concerns about deliberate harm as safeguarding issues requiring urgent action. Lady Justice Thirlwall made a series of recommendations aimed at preventing similar failures in future.
Dr Clea Harmer, Chief Executive of Sands, said: “The Thirlwall report must be acted on with a recognition of the wider systemic failures we have seen across maternity and neonatal care, and which have also been highlighted in many previous reports.”
“We strongly welcome the recommendation that listening to the voices of bereaved parents must be at the heart of all policies to save babies’ lives and improve future care. And that the National Bereavement Care Pathway, which Sands leads in England, should be implemented in all Trusts in England by August next year.”
The pathway is designed to ensure bereaved parents receive consistently high-quality, compassionate, and personalised support following the death of a baby. Under the inquiry’s recommendation, it must be implemented nationally by 31st August 2027.
Dr Harmer added: “Other key issues that must be addressed include whistleblowing and senior doctors’ concerns being ignored with no effective escalation route, and a lack of training and regulation for NHS managers.”
The report recommends stronger whistleblowing processes, clearer escalation routes when senior clinicians raise concerns, and improved training and regulation for NHS managers.
The government has indicated that it will consider the full set of recommendations. In an initial response, the Health and Social Care Secretary apologised to the families and outlined steps already under way, including work on video monitoring in neonatal units and the continued rollout of the bereavement pathway.
Sands said the problems identified at the Countess of Chester form part of a broader pattern, pointing to previous inquiries and reports into maternity and neonatal services that have highlighted concerns about listening to parents, protecting staff who raise concerns, and ensuring accountability among managers.
The National Maternity and Neonatal Taskforce, established to drive improvements across these services in England and chaired by the Health and Social Care Secretary, brings together families, clinicians, and other experts to develop and oversee a national action plan. Sands regards the taskforce as a critical vehicle for delivering lasting change.
Dr Harmer said: “However, simply implementing the recommendations from today’s report is not enough. Families are suffering avoidable harm and loss because the current system is broken. The National Maternity and Neonatal Taskforce now has a once-in-a-generation opportunity to deliver the transformational system-wide change required to make care safer. This is the moment for transformational change, and Sands is ready to be a part of it.”
Whether the inquiry’s emphasis on placing bereaved parents’ voices at the centre of future policy, a principle Sands has long advocated, is fully translated into practice will be a key test of the response in the months and years ahead.
Anyone affected by the issues raised in this article can find support through Sands’ website or helpline.