Report for the Thirlwall Inquiry: Analysis of questionnaires from 120 NHS trusts (Nuffield Trust, 24 March 2025)

Summary

The Thirlwall Inquiry was set up to examine events at the Countess of Chester Hospital following the trial and subsequent convictions of Lucy Letby for the murder and attempted murder of babies at that hospital. This report was commissioned by the Thirlwall Inquiry. It summarises key themes from responses to a questionnaire sent by the Inquiry to all other NHS trusts with maternity and neonatal units in England. With the evidence and submissions phase of the Inquiry now closed, the Nuffield Trust publish it here in the form submitted to the Inquiry as of April 2024.

Content

Overarching themes

• For almost all the areas covered in the questionnaire there were existing regulations, mechanisms or guidance in place in the NHS. Within neonatal services there were additional reporting routes and requirements to take into account over and above those which apply across the NHS as a whole. In a small number of areas (for example use of CCTV) we found limited guidance.
• The infrastructure within trusts affected the processes they have in place to manage safety and risks. For example, there was variation between trusts in the availability of electronic systems to support access to medical records, medicines management and storage facilities, the maturity of systems for data collection, reporting and triangulating information, and ease of access to the ward for parents.
• However, policies, structures and processes on their own are not sufficient to ensure services are safe and effective. A wide body of research indicates that culture and leadership are critical, and a positive culture is needed for systems and processes to achieve their aims. Where there is variation in how trusts manage issues, this will reflect a combination of the circumstances of the organisation and the leadership approach to addressing issues.
• Some organisational circumstances are unique, but there are many factors affecting the whole NHS, or neonatal care specifically, for example resource and workforce pressures. Culture and leadership at an organisational level are also impacted by national leadership and management of the NHS. In some cases the quantity of guidance, reporting requirements, number of external regulators, and the frequency with which these change, leads to a risk that responding to external scrutiny takes precedence over learning and action within the organisation.