The government has announced a major overhaul of NHS safety and accountability measures following the publication of the Thirlwall Inquiry report, which found a “complete failure” to protect babies at the Countess of Chester Hospital between 2015 and 2018.
On 15 September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, issued a formal apology to the families in the House of Commons. The Health Secretary admitted that the findings represented a complete failure to protect babies, criticising a “no blame” culture that allowed managers to avoid responsibility.
The government has committed to implementing 14 recommendations from the inquiry, led by Lady Justice Thirlwall. These measures are designed to ensure that the events at Chester, where institutional failures allowed serial attacks on vulnerable infants to go undetected, can never be repeated in any English hospital.
New Regulation for NHS Managers
One of the most significant changes is the introduction of a statutory barring system for NHS managers. Under the new rules, which the government intends to have in place by September 2027, senior hospital administrators will be subject to professional regulation similar to that of doctors and nurses.
This move aims to end the “revolving door” of management where individuals can move between trusts despite significant failings in patient safety or conduct.
In addition to manager regulation, the government has mandated that all hospital trusts must have board-level monitoring of child and baby deaths in place by April 2027. This is intended to ensure that any unusual patterns or clusters of deaths are identified and scrutinised at the highest levels of hospital leadership immediately.
Safety Technology in Neonatal Units
The government has also ordered the urgent development of plans for “cot cams” – video baby monitors – in all neonatal units across the country.
The monitors will allow parents to see their babies remotely and are seen as a critical step in providing transparency and reassurance in neonatal care.
Specific technical recommendations to improve security in wards are also being implemented:
- New controls on insulin storage are being mandated to prevent unauthorised access.
- CCTV will be required for storage fridges where digital access logs are not yet available.
Ongoing Investigations
While the Thirlwall Inquiry focused on the institutional failures and the culture of the NHS, separate criminal investigations remain active. Cheshire Police are continuing Operation Duet, an investigation into corporate manslaughter at the Countess of Chester Hospital.
Lady Justice Thirlwall’s report highlighted that the “no blame” culture within the hospital leadership at the time had prioritised the reputation of the trust over the safety of the patients. The Health Secretary stated that the new measures represent a “fundamental shift” in how the NHS handles patient safety and accountability.
