Learnings For Local Government From The Thirlwall Inquiry

The Thirlwall Inquiry into the crimes of Lucy Letby carries clear lessons for organisations beyond the NHS. As statutory safeguarding partners, local authorities should review how the inquiry's findings — on evidential thresholds, LADO referrals, child death review arrangements, and safeguarding culture — apply to their own partnership arrangements, and take practical steps to drive improvement across the system.

The inquiry and its wider significance

The Thirlwall Inquiry examined the circumstances in which Lucy Letby, a neonatal nurse at the Countess of Chester Hospital, killed or caused serious harm to babies in the hospital’s care. Its terms of reference covered the conduct of hospital management, the effectiveness of governance and safeguarding systems, the role of regulatory and oversight bodies, and whether existing policies and procedures were adequate to protect patients.

The findings are striking: lives may have been saved by the right safeguarding response, and the report sets out a number of areas for improvement in safeguarding in hospital settings.

Safeguarding is everybody’s business, and this article considers what the report means for local authorities: not simply in relation to learning points that can be carried over, but as statutory safeguarding partners with a role in working across the system to improve safeguarding for all children in their area.

Organisations are in different places

One of the most important observations to draw from the Thirlwall report is that safeguarding understanding, culture and operational practice vary, not only between sectors but within organisations and across different parts of the same system. Survey evidence gathered by the Inquiry supports the view that there is wide variation between trusts in governance, policy and culture. The picture, then, will not be uniform but it is important to be aware of some of the ways in which the inquiry observed safeguarding could fall short.

Evidential thresholds: Waiting for proof rather than acting on suspicion

A recurring feature of the evidence was the belief that action required 'evidence'. Concerns were repeatedly met with the response that there was 'no evidence' linking any individual to the deaths and that the association could be explained by working patterns or allocation to sicker babies. Others felt unable to raise concerns without 'actual evidence', treating the absence of proof as a reason for inaction. The Inquiry is direct in its rejection of this approach: it should be completely understood that there is no evidential requirement before action is taken, and once suspicion of harm is reported in good faith, managers and leaders must act.

Safeguarding not at the centre of the organisational response

When a concern is emerging and evidence is limited, it is natural to seek further expertise from senior colleagues or through internal governance. The Inquiry records examples of this at the Countess of Chester, including the involvement of the Neonatal Network to provide external objectivity. What the evidence also makes clear, however, is that seeking expert opinion must run alongside safeguarding processes rather than serve as an alternative to them. The Chief Executive, who was also the Trust's Executive Lead for Safeguarding, accepted that safeguarding actions, including referral to the LADO and police involvement, should have been taken, rather than the approach of monitoring and waiting for further incidents. One of the functions of safeguarding as a system is precisely to draw on wider information and identify patterns. Where concerns are handled as a series of separate incidents, without safeguarding involvement, that system-wide picture cannot emerge.

Treating concerns as HR or employment matters rather than safeguarding

Professor Dixon-Woods identified an absence of clarity in employment policies for handling highly transgressive events. Where the risk of deliberate harm was acknowledged at the Countess, it appears to have been considered as a matter for HR rather than as an issue of patient safety. The Inquiry is clear that when patient safety or safeguarding concerns are raised in good faith, the balance must come down firmly in favour of protecting the patient, not in favour of managing an employment relationship. 

Subjecting those who raise concerns to HR and disciplinary processes

Perhaps the most significant concern identified is what happened to those who did speak up. Some staff received letters referencing potential GMC referral, were criticised through a grievance process, and were required to apologise. One raised concerns of not being believed and of accusations of bullying as factors that prevented him from raising his suspicions at the time. When raising a safeguarding concern becomes personally costly, this suppresses the ability of staff to raise their concerns as part of the safeguarding system.

Drawing on safeguarding strengths and working to address safeguarding weaknesses

These types of failure do not require bad intent to arise in an organisation. They can reflect the professional cultures, governance habits and risk instincts of organisations that, in other respects, operate carefully and responsibly. They are, however, recognisable risks in any organisation with safeguarding responsibilities, and any honest safeguarding partnership should be willing to ask whether any of them is present in its own arrangements.

The report also discusses examples of cultures in which safeguarding is strongly supported. Schools have a clear and commonly understood safeguarding response when deliberate harm by a member of staff is suspected — typically moving the person to a no-harm role or excluding them pending investigation, which is treated as a neutral act, even though many such concerns ultimately come to nothing. That clarity did not emerge from nowhere; it was built through statutory frameworks, guidance and, in many cases, the hard lessons of earlier inquiries and reviews. The lesson is not that one sector has succeeded where another has failed. There will be variance in every sector, and it is important to be alert to this. However, the contrast does give assurance that clarity as to the overriding importance of safeguarding and procedures which reflect this, once developed, is genuinely protective. 

The Inquiry's proposed response is a practical one: a Suspicion of Deliberate Harm Protocol, so that staff and managers are in no doubt what to do, with no evidential requirement before action is taken. The protocol would make clear that disputes about belief or credibility are irrelevant; that good-faith concerns must be acted on immediately; that moving the suspected staff member is likely to be the first step and is a neutral act; and that safeguarding steps must be followed, which will in many cases lead to police involvement. Trusts would be required to embed the protocol within the hospital. For those working in children's social care and education, the logic will be familiar. Its formal application to acute health settings is a central recommendation of this Inquiry.

Every safeguarding incident occurs within a safeguarding partnership

The most significant structural point the Thirlwall report raises for local government is that no safeguarding incident occurs in isolation from the broader safeguarding system. The events at the Countess of Chester Hospital occurred within a safeguarding partnership. There were partnership mechanisms that should have been engaged and were not. For the most part, this arose from internal decisions which meant the local safeguarding arrangements were not engaged. 

With a view to learning from the inquiry, any organisation in a safeguarding partnership should now be asking itself “How can we ensure this does not happen within our partnership arrangements?”

Section 16E of the Children Act 2004 provides that the safeguarding partners for a local authority area (the local authority, the integrated care board and the chief officer of police) must make arrangements for those partners, and any relevant agencies they consider appropriate, to work together to safeguard and promote the welfare of children in the area. 

Achieving this depends on individuals, agencies and organisations being clear about each other's roles in the partnership, and their processes for working together. But if this is to meaningfully support safeguarding in an area, each partner must also be able to assure itself that its partners and relevant agencies (which includes NHS trusts in the area) have the necessary internal processes to engage with wider safeguarding structures. 

Safeguarding failures often arise through gaps or ‘weak links’ in safeguarding systems. Indeed, there are too many examples of people intent on harming or abusing children who have targeted specific organisations or activities based on where detection is least likely. Safeguarding partners and other organisations in the safeguarding system need to be clear-eyed as to differences in safeguarding practice. As custodians of the system, safeguarding partners need to work actively and constructively to understand where practice can be improved and to work with relevant organisations to achieve this.

The LADO: A key safeguarding gateway

One of the most direct connections between the Thirlwall report and local authority safeguarding functions is the explicit identification of the Local Authority Designated Officer as a key gateway in the safeguarding response to suspected deliberate harm by a worker.

The Inquiry is clear that once suspicion of harm by a member of staff was present, a referral to the LADO should have been made. Working Together 2026 requires local authorities to designate a LADO to manage and oversee allegations against adults working with children, to be notified within one working day of relevant allegations, with the LADO providing advice and guidance to employers. An allegation for these purposes includes behaviour that has harmed or may have harmed a child, possible criminal offending, or behaviour indicating a risk of harm or unsuitability to work with children. 

The failure to engage the LADO function was not a failure of the LADO. It was a failure of the internal processes at the Trust to activate the multi-agency architecture that existed. But understanding this raises a clear opportunity for improvement: Could more be done within local arrangements to help relevant agencies and their staff understand the threshold and process for a LADO referral? 

Key recommendations interacting with local authority processes

The Inquiry made 17 recommendations, the majority directed at NHS organisations and NHS England. Several, however, have direct or indirect significance for local authority safeguarding partners.

Suspicion of Deliberate Harm Protocol

The Inquiry recommends a new protocol providing step-by-step clarity so that staff know what to do when deliberate harm is suspected, including when to involve police and how parallel investigations interact. The recommended protocol is explicit that good-faith concerns must be acted on immediately, that moving the suspected staff member is a neutral act, and that safeguarding steps, including, where appropriate, police involvement, must be followed. For local authority safeguarding partners, this raises a practical question: once such a protocol is in place, how will the partnership provide assurance that it is embedded and understood by local NHS trusts? 

SUDIC guidance and multi-agency response

The Inquiry states that SUDIC guidance must be updated to clarify that it applies to neonatal deaths in hospital settings. The procedures that should follow a child's death include immediate decision-making and notifications, investigation and information-gathering, and a review meeting involving relevant agencies. Local authorities and their child death review partners should ensure that revised SUDIC guidance is embedded in local child death review arrangements, and that there is shared understanding across all agencies of when and how it applies.

Medical examiners and LADO referral

The recommendation that medical examiners use a checklist including consideration of a LADO referral is of direct significance for local authorities. It means the LADO role will become a more visible element of the response to neonatal deaths where concerns arise. Local authorities should ensure that the LADO function and referral pathway are clearly communicated to NHS trust partners, and that the LADO team is prepared for potential referrals from this source and understands the checklist prompts leading to referral.

Regulation of NHS managers

The report recommends new regulation applying not just to clinicians but to managers and senior leaders, with the government confirming plans for a barring scheme. This is relevant to the LADO function insofar as allegations against NHS managers will need to be considered within the existing statutory framework for managing allegations against people who work with children. Local authorities should engage with how the new managerial regulation interacts with existing LADO processes.

How can local authorities use their safeguarding partnership role to drive improvement?

Raising the report within the partnership

The Thirlwall report is precisely the kind of national learning that the safeguarding partnership should actively consider. Local authorities can ensure that the report's key findings and recommendations are on the partnership agenda and that safeguarding partners and agencies are actively looking at how to improve while the recommendations are put into effect.

Reviewing child death review arrangements

Child Death Overview Panels are required to review deaths of children resident in their area and may review other child deaths occurring in their area. This should be determined by liaison with the CDOP of residence based on where the most learning can take place. The goal is a robust, standardised review process so that learning can be captured locally and thematically at national level to identify common factors and prevent future deaths. Where neonatal and other acute health settings attract non-resident children, there is a clear argument for the CDOP in whose area they are based to coordinate all reviews, to support systematic learning. 

Supporting NHS partners in understanding the LADO pathway

As the employing authority for the LADO, and as the statutory partner responsible for arrangements for managing allegations against people who work with children, the local authority is well placed to provide guidance and briefing to NHS trust partners on the circumstances in which LADO referral is appropriate and how the process works. The Inquiry's explicit identification of the LADO referral as something that should have happened is an opportunity to reinforce that connection.

Ensuring information flows

Missed opportunities to record and share information can have severe consequences, and common barriers, including myths about data protection, must not stand in the way of safeguarding. Professionals across all agencies must notify CDOP, share information, and participate in local review arrangements when involved with the child or family. Local authorities can review whether information-sharing protocols with local NHS trusts are fit for purpose and whether they are being used effectively.

Partnerships driving ongoing improvement

There is much in this Inquiry that every safeguarding partnership should reflect on carefully. 

Process compliance and outcome achievement are not the same thing. Bodies can fulfil their procedural obligations - conducting reviews, attending panels, filing notifications, and still fall short of the outcome those processes were designed to deliver. Safeguarding arrangements should be evaluated not by whether the processes are running but by whether children are, in practice, better protected as a result.

The question is not only "are we complying?" but "are children safer because of what we do?" That question, asked honestly, across every organisation in the partnership and in every sector, is the most important lesson the Thirlwall Inquiry offers to those in local government with safeguarding responsibilities.