- 17 September 2026
In response to the Thirlwall Inquiry report Linda Ford, Chief Executive of The Chartered Governance Institute UKI, said:
"The experiences of the families whose babies died or were harmed at the Countess of Chester Hospital must remain central to the response to this inquiry.
The failures documented in the report have had devastating consequences, and those governing healthcare organisations should now consider all the recommendations.
There are many governance proposals. One of the clearest is that every hospital trust should have effective board-level oversight of the deaths of babies and children, backed by an established route for escalating worrying trends. At the Countess, the board did not receive any reports about those deaths at any stage between 2015 and 2018.
Boards need reliable information about serious risks. They need the data to understand when patterns are emerging and must be able to interrogate what they are being told.
Reassurance should be checked against the facts. Boards and executives have to be willing to hear unwelcome news and act quickly when credible concerns are raised.
The Inquiry shows what can happen when safeguards fail. Warning signs were considered in isolation, and established governance and risk processes did not lead to the action required to protect patients. Too much weight was given to believing and supporting staff, and too little to the safety of vulnerable babies. The hospital had a whistleblowing policy, but it did not work for the doctors who raised concerns.
In previous statements on reviews, we emphasised that the test is implementation. The Thirlwall Inquiry found that most recommendations from previous NHS inquiries have not been implemented. Independent scrutiny of implementation will be necessary if the lessons identified today are to lead to real change."