The Government has announced a series of immediate actions to strengthen patient safety, safeguarding and accountability across the NHS following the publication of Lady Justice Thirlwall's final report into events at the Countess of Chester Hospital.
The Inquiry identified significant failures in governance, leadership and safeguarding, concluding that multiple opportunities were missed to respond to concerns and protect vulnerable newborn babies from harm. In response, the Health and Social Care Secretary told Parliament that safeguarding must become a central priority across the NHS and confirmed that ministers will act on the Inquiry's recommendations to help prevent similar failures in the future.
While the Government undertakes a detailed review of the report, work has already begun on several measures designed to improve oversight, transparency and patient safety across maternity and neonatal services.
Among the first steps announced are plans to introduce CCTV monitoring, including the use of "cot cams" in neonatal units, aimed at enhancing safety standards and providing reassurance for parents.
The Department is also developing new guidance covering the storage and use of insulin, alongside strengthened guidance for Medical Examiners responsible for reviewing neonatal deaths.
In a significant move to improve accountability, ministers are progressing plans to regulate NHS managers through a barring scheme that could prevent senior leaders who fail in their responsibilities from holding future leadership positions.
Support for bereaved families is also being strengthened through the continued national rollout of the Bereavement Care Pathway. All NHS trusts have now committed to implementing the programme, ensuring more consistent support for families affected by neonatal loss.
To improve oversight of sector-wide reforms, the Government will create a single national tracker to monitor recommendations arising from major maternity and neonatal reviews and inquiries. The aim is to provide greater transparency and ensure improvements are delivered consistently across the health service.
Speaking in Parliament, Health and Social Care Secretary Yvette Cooper said:
"The safety and care for babies, the safeguarding of every patient, the respect for families – all these goes right to the heart of our NHS values.
“The Inquiry recognises that in many areas things have changed since these terrible events took place including welcome improvements at the Countess in services for women and children.
“However the inquiry is clear that new action is needed.
“I take these recommendations extremely seriously and the Government will of course consider the entire report and set out a full response.
“Safeguarding is everyone’s business, and safeguarding must be everyone’s priority. Concerns must be heard and acted upon. Staff who speak up must be protected and taken seriously, and I expect every leader, every board across the NHS, every professional and manager, every member of staff, to uphold their safeguarding responsibilities."
The Secretary of State also confirmed that safeguarding principles will be embedded within the forthcoming Babies, Children and Young People's Modern Service Framework, reinforcing the Government's commitment to placing the safety and wellbeing of babies and children at the centre of healthcare delivery.
The announcement coincided with the Health and Social Care Secretary's first meeting as Chair of the Maternity and Neonatal Taskforce. The taskforce has been established to turn recommendations from the Ockenden and Amos reviews into a practical action plan for improving maternity and neonatal care across England. That plan is expected to be published later this year.
The Government has said it will publish a full response to all recommendations made by Lady Justice Thirlwall once the report has been considered in detail.
The Health Secretary also said:
“The suffering endured by these babies and their families is impossible to comprehend.
“On behalf of the government and the health service, I am profoundly sorry for the failures set out so clearly in this report.
“For the harm, distress and unthinkable loss for their families. For the failures by the NHS to keep babies safe. “
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