Thirlwall Inquiry Report Published: Key Findings And Bond Turner’s Response (Video)

Thirlwall Inquiry Published

The final report of the Thirlwall Inquiry has been published, identifying serious failures in management, governance and safeguarding at the Countess of Chester Hospital and setting out 17 recommendations intended to improve the safety of babies receiving hospital care.

Published on 15 September 2026, Lady Justice Thirlwall’s report examines events at the hospital between 2015 and 2018, following the trial and subsequent convictions of former neonatal nurse Lucy Letby.

Bond Turner acted as a Core Participant in the Inquiry, representing the families affected by the events at the Countess of Chester Hospital and helping to ensure that their experiences and concerns formed part of its examination.

Key Findings of the Thirlwall Inquiry

The report found that:

• There was a complete failure to protect babies on the hospital’s neonatal unit.
• Concerns raised by consultants were not acted upon with the urgency they required.
• Senior managers failed to understand that concerns about possible deliberate harm should have triggered immediate safeguarding action.
• Senior nurses did not accept that the consultant’s concerns might be justified, while there was a prolonged delay in contacting the police.
• Internal and external reviews failed to properly address whether deliberate harm was being caused.
• Clinicians who raised concerns became the subject of investigation, while parents were kept uninformed about concerns and reviews involving their babies.
• Some babies would have been saved and some attacks prevented if appropriate action had been taken sooner.

The report makes 17 recommendations addressing neonatal monitoring, safeguarding procedures, access to insulin, NHS leadership, data reporting, regulatory inspections and implementation of recommendations arising from public inquiries.

The complete report and recommendations are available on the Thirlwall Inquiry website.

Bond Turner Responds to the Thirlwall Inquiry Report

Carla Duprey, Senior Solicitor at Bond Turner, said:

“Today’s publication of Lady Justice Thirlwall’s report represents an important moment in understanding what happened and, crucially, why it was allowed to happen.

“On behalf of Bond Turner, we welcome the clear identification of serious failings and the scrutiny that has been applied to the actions, decisions and systems surrounding these events.

“For those of us representing families affected by what happened, the importance of these findings cannot be overstated. There has been a very long wait for answers, and it is vital that the failings identified are properly acknowledged and that meaningful lessons are learned.

“However, it is important that we do not comment on the report in detail before we have all had the opportunity to properly consider it. It is a substantial report, and we will need time to digest its findings in full, consider the detail and assess what its conclusions mean in the wider context.

“We will therefore be taking time to carefully review and will provide further comment once we have had the opportunity to do so.

“What matters now is that the findings are properly understood, that the recommendations receive the attention they deserve, and that they lead to meaningful and lasting change.

“While today’s report is an important milestone, nothing can undo the loss of the babies who died, the harm suffered by those who survived, or the enduring trauma experienced by their families. For the families involved, the consequences have been life-changing and continue to this day.”