The Thirlwall Inquiry has today published its final report, at the conclusion of this statutory inquiry 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.
Bliss, the UK’s leading neonatal charity, would like to start by expressing our deepest sympathies to the babies and families affected. We also know that news of the Inquiry’s final report will be particularly hard for those with their own neonatal experiences, as well as for the healthcare professionals who work tirelessly to support babies born premature or sick. Our comment focuses on the recommendations made in the Inquiry’s final report that are applicable or relevant to neonatal services nationally, as well as the impact this report is likely to have on neonatal families and professionals more widely.
Families, if you need support, we are here for you: send us a DM or email us at [email protected].
Caroline Lee-Davey, Chief Executive of Bliss said, “The events which took place at the Countess of Chester Hospital, which are the principal subject of this Inquiry, are incomprehensible. On behalf of everyone at Bliss, I want to acknowledge the devastating experiences of the babies and families at the heart of this Inquiry - there are no words for what they have gone and continue to go through, and our deepest sympathies are with them.
“I also know that the information in the Inquiry’s report will be hard to read and understand for all families with their own neonatal experiences, including families with babies currently in neonatal care, as well as for the many healthcare professionals up and down the country who work tirelessly to support babies born premature or sick.
“Lady Justice Thirlwall has set out a damning analysis of what happened at the Countess of Chester, and a clear set of recommendations to improve neonatal safety – as well as NHS culture and practice more widely – in future. These recommendations go to the heart of ensuring the safety of some of the most vulnerable patients in the NHS, and it is vital that the Government provides the funding required to implement them in full, with national prioritisation of next steps and allocation of responsibility to specific bodies or individuals to implement set actions.
“This report is published at a time when neonatal services in England are already under scrutiny following the publication of the National Maternity & Neonatal Investigation Final Report in June 2026 and the ongoing work of the Maternity & Neonatal Taskforce to develop a National Action Plan. Following repeated failures by other reports to adequately consider the needs of babies as patients in their own right, the Thirlwall Inquiry provides a stark reminder that neonatal care must be paid due attention, alongside – but distinct from – maternity care.
“Indeed, the Inquiry report highlights the importance of there being sufficient specialist neonatal expertise within a range of relevant professions – including medical examiners, pathologists, and NHS Trust senior managers – so that, as Lady Thirlwall noted in her statement, ‘Deaths of babies should never again go unnoticed by the Board of a hospital’. At national level, however, Lady Thirlwall commented that ‘DHSC and NHS England again were not able to set out how neonatal-specific issues will be addressed in practice [by the National Maternity and Neonatal Taskforce]’, and it is critical that this need for clear national leadership is addressed.
“The Inquiry report also describes a dismissive culture towards the parents, which tragically reflects a pattern of behaviour towards parents found in other, particularly maternity, reviews after incidents of harm or loss. At Bliss we have worked over many years to support parents as partners in their baby’s neonatal care, and this report must be a watershed moment in ensuring that all families who are affected by neonatal harm or death are treated with honesty and respect through whatever review process may follow.
“To parents of babies currently in neonatal care, I say this: we understand how troubling today’s report may be for you, and Bliss is here to support you through every step of your baby’s neonatal stay. You know your baby best, and if you have any questions or concerns about their care then please do raise these as soon as possible with your baby’s clinical team – they will want to work with you as partners to ensure your baby gets the very best care. You can find more information about how to do so here https://www.bliss.org.uk/parents/support/raising-concerns-about-your-babys-care, and you can contact Bliss at [email protected] or via our social channels at any time.”
