Yvette Cooper

May I apologise for the timing of the statement and thank the Opposition for their understanding? With permission, Madam Deputy Speaker, I shall make a statement on the report of the three-year public inquiry into events at the Countess of Chester hospital between 2015 and 2018 led by Lady Justice Thirlwall, published today. I am grateful to Lady Justice Thirlwall for her thorough and devastating report. At the heart of the inquiry have been 13 families who lost their newborn babies or who saw them experience serious collapse or injury at the hospital 10 and 11 years ago. I cannot begin to fathom the grief and pain of the parents and families. The mother of Baby J describes her grief: “I cannot emphasise enough the impact of this on our whole family. Who we are as people, parents, work life, spouses, children…[it] has cast a shadow of sadness over every part of our lives.” Those parents have had to face the unimaginable. I recognise that they have waited many years for the details set out in this report and that it will continue to add to the distress and the loss that they have endured. They should be in all our thoughts throughout all the discussions of today’s report. The public inquiry was commissioned by the then Health Secretary in September 2023, following the conviction of neonatal nurse Lucy Letby for the murder of seven babies and the attempted murder of a further six babies. Lady Justice Thirlwall has been clear that it was not her role to look at the convictions, the legal process, or the court evidence, and she is explicit about not cutting across the work of the Criminal Cases Review Commission. Instead, her focus was on the experiences of the parents of the babies named in the indictment, the conduct of those working at the Countess of Chester hospital, including whether action should have been taken earlier, and the effectiveness of NHS management, governance, scrutiny and regulation in keeping babies in hospital safe. That is also the focus of this statement. In the words of Lady Justice Thirlwall, “The Report sets out a dispiriting and at times shocking account of multiple and repeated mistakes and failings by organisations and individuals.” The inquiry describes the increase in neonatal deaths in 2015 and 2016 at the hospital, the concerns about the possibility of deliberate harm that were raised by clinicians at an early stage, but then the repeated failures of organisations and individuals to act: shocking failures to put the safety of babies first; shocking failures on safeguarding; failures in governance and in regulation; failures in the most basic duty of candour; failures in professional curiosity; and repeated failures to refer concerns to the police, which the inquiry is clear should have been done at a much earlier stage. Lady Justice Thirlwall comes to the devastating conclusion “that some babies would have been saved…if action was taken earlier.” Central to the findings are what Lady Justice Thirlwall describes as “complete failure at all levels to invoke safeguarding procedures at any point.” She explains: “No one seems to have thought that safeguarding action is required when a member of staff is suspected of causing deliberate harm. Suspicion is enough.” The inquiry also identifies failure among external bodies, including the Care Quality Commission, which failed to consider the data and ask the right questions, and the Royal College of Paediatrics and Child Health, which should have known as soon as it was engaged that this was a matter that needed to be referred to the police. The inquiry finds repeated failures of governance and candour by the trust and by individuals within it. Disturbingly, it refers to an “exercise in spin” to steer away from referral to the police. That is an appalling finding—an exercise in spin instead of putting the safety of babies first. Worst of all, the trust repeatedly failed the parents: it failed to keep their beloved babies safe; it failed repeatedly to provide them with information which they had a right to know; and it failed to ask their consent for sharing information with external experts and other organisations, or to keep them up to date with investigations. For parents to be kept in the dark for years about what was happening is, as Lady Justice Thirlwall has said, “reprehensible”. Let me address the issues for the families and the parents directly. The suffering endured by the 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 the report, for the harm, distress and unthinkable loss for their families, and for the failures to keep their babies safe. Our responsibility now is to act. Let me be clear: the safety and care of babies, the safeguarding of every patient, the respect for families—all those go to the heart of our NHS values. They must be at the heart not just of what we say, but what we do. Let me turn to the recommendations. Lady Justice Thirlwall has made 17 recommendations on what needs to be done to keep babies safe. The inquiry recognises that in many areas things have changed since the terrible events took place, including welcome improvements at the Countess hospital in services for women and children. However, the inquiry is clear that new action is needed. I take the recommendations extremely seriously. The Government will, of course, consider the entire report and set out a full response, but let me highlight some key areas today. On the crucial issue of safeguarding, Lady Justice Thirlwall recommends compulsory training, a new protocol and employment requirements. A revised NHS safeguarding framework was published in April 2026, but I have asked the chief nursing officer to urgently review the framework and the training in the light of the report. We need to look urgently at that. Let me be clear: this goes beyond laws and procedures, many of which are already clear; this is about leadership and responsibility. 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. I expect every leader, every board across the NHS, every professional, every manager and every member of staff to uphold their safeguarding responsibilities. I will not hesitate to hold the NHS to account for the highest standards at every level, because at its heart, this is what the NHS stands for: care for patients and, most of all, keeping the most vulnerable patients of all safe. On safety and reassurance for parents, Lady Justice Thirlwall recommends the introduction of video baby monitors for neonatal units. I agree. I have asked my officials to urgently develop plans for cot-cams, which can also help parents feel better connected to their babies when they are unable to be with them in person. The inquiry says that the sudden unexpected death in infancy and childhood guidance must be updated. I agree. That is now under way. It welcomes the introduction of medical examiners but says that this should have happened 10 years earlier. I agree. We will set out further plans to strengthen their neonatal expertise following the inquiry’s recommendations when the Government set out their full response. The inquiry recommends much stronger controls on insulin storage. The NHS has begun that process with new guidance in January this year, but we agree with the recommendation to go further. It recommends new regulation on NHS managers, not just on clinical professionals. The Government have consulted on and confirmed plans to apply a barring scheme to senior leaders and managers, not just to clinicians. We will legislate to introduce the scheme as soon as parliamentary time allows, and we will consider the chair’s recommendation to expand it further. The report also makes recommendations for the regulators, including the CQC, which we will ensure are taken seriously. On technology, we have implemented the maternity outcomes signal system, which provides near-real-time safety alerts, but we agree that we must do more. I agree with the report that when the very worst happens and parents face bereavement, they need to be supported to the best of our ability. The report recommends that the national bereavement care pathway for neonatal death should be rolled out in 2027. I agree, and can confirm that all trusts are signed up to implement it. I will ensure that it is repeated in all versions of the NHS planning framework while I am the Secretary of State. Lady Justice Thirlwall highlights problems with past inquiry recommendations not being implemented, so my Department is setting up a recommendation hub to properly track our implementation progress internally, not just for this inquiry but for others right across the NHS. But we will work with the Cabinet Office now on improvements in this area, to respond to this inquiry. This afternoon I will discuss with the maternity taskforce our plan to bring forward amendments in the Health Bill to create a new maternity and neonatal commissioner to address the serious concerns around safety and standards that have been raised. Later this week, I will meet Lady Justice Thirlwall to discuss how we take forward the report’s conclusions. I want to highlight a final issue that has struck me while reading through the different volumes of this inquiry. A section of the report refers to the way senior oversight of neonatal care had been downgraded in the reorganisation of the Countess hospital. It includes the fact that the board and the medical director reviewed deaths within the hospital. However, this only covered adult deaths. The report says that “the Board did not receive any reports about the deaths of babies and children at any stage during the period I am considering. This was a serious failure of governance, which no one on the Board seems to have noticed. This is further evidence of the inadequacy of the structure, which removed the voice of children and babies from the Board, and the lack of profile of paediatrics and neonatology.” I am clear that the safety, safeguarding and wellbeing of babies must never again be treated as a side issue. As I reflect on some of the safety reports on maternity services we have seen in recent years, let me also be clear that maternity and neonatal services cannot operate on the margins. They must be at the forefront—a central priority in what our NHS must do at the vital and precious start of a family’s life. I want to thank the families for the extraordinary courage and dignity they have shown. I also thank Lady Justice Thirlwall and her team for their rigorous work. This must be a turning point for the NHS. When concerns are raised, especially about safety and safeguarding, they must be heard and acted upon, and it is time to put maternity and neonatal care and safety at the top of the NHS agenda, where they belong. I commend this statement to the House.