Following the publication of the Thirlwall Inquiry report, Trusts have been instructed to take immediate action on some of its recommendations in a letter from Sarah-Jane Marsh, NHS England Chief Operating Officer and Duncan Burton, Chief Nursing Officer for England.
Specifically, the letter requires Trusts to review the report, to undertake urgent work around security and access control for insulin storage areas, review safeguarding and communicate relevant protocols and care pathways to staff.
Action is not just required by Trusts with neonatal services, as some of the issues uncovered by the report relate to the care, safety and safeguarding of all patients and therefore “clear action” is required by all Trusts. “It is a matter for every single Trust and Integrated Care Board (ICB) to consider, and for every member of staff across the NHS.”
The Government is committing to urgent work to develop plans for baby monitors – in-cot cameras with livestreaming video – to be fitted for all cots and incubators in all neonatal units. This will enable parents to observe their baby remotely at all times. A national approach will be developed to support this, taking learning from hospitals which already use this technology.
It will also go further on guidance over the safe use and storage of insulin, undertake a review of safeguarding training, work through plans to regulate NHS managers through a barring scheme for those who fail in their responsibilities and continue to roll out the National Bereavement Care Pathway.
Action required now by Trusts
Guidelines for the safe use and storage of insulin are set out in ‘GIRFT Neonatology: Guide to safe insulin use’ and the letter requires Trusts to go further and faster in their compliance. By November 30, 2026 at the latest, each Trust must have installed CCTV cameras in neonatal units, focused on storage fridges, cupboards or other units, and recordings should be stored for at least 28 days. This is until access to insulin requires the provision of biometric data. By March 31, 2027, all neonatal units must meet the requirements for access and storage of insulin as set out in the GIRFT guidelines.
Every Trust and ICB board must review the Thirlwall report and consider its findings at the next available public board meeting, assessing whether it would be possible for similar events as those at the Countess of Chester Hospital to have happened at one of their facilities.
The Thirlwall Inquiry makes it clear that no member of staff should ever claim they did not know what to do in response to a sudden and unexplained death. By September 28, 2026, all Trusts with a neonatal unit must communicate the SUDIC (Sudden unexpected death in infancy and childhood) protocol to all relevant staff and the Board.
All Trusts and ICBs should ensure all staff and board members are compliant with safeguarding training requirements appropriate to their seniority and know who to raise and escalate concerns to.
Finally, all ICBs and providers should take immediate action to improve care of the bereaved, as set out in the Medium Term Planning Framework (October 2025).
