Yvette Cooper says plans for cot cams in neonatal units to be ‘urgently’ developed
The health secretary said she has asked officials to develop plans to install “cot cams” in neonatal units.
She told the House of Commons:
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 aren’t able to be with them in person.
The government takes the recommendations from the Thirlwall inquiry “very seriously”, Cooper added.
Key events
Poorly-performing NHS managers to be removed under new barring system, Cooper says
Cooper also told MPs that she will legislate to bring in a barring system to remove poorly-performing NHS managers “as soon as parliamentary time allows”.
The health secretary said:
The government has consulted on and confirmed plans to apply a barring scheme to senior leaders and managers, not just to clinicians.
So, we will legislate to introduce the scheme as soon as parliamentary time allows and we will consider (Lady Justice Thirlwall’s) recommendation to expand it further.
In line with one of the recommendations in the report, the health secretary, Yvette Cooper, said all NHS trusts are signed up to roll out the national bereavement care pathway in 2027, which is meant to ensure high quality and consistent bereavement care throughout the UK, ending the current postcode lottery of provision.
“The report recommends 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,” Cooper told the House of Commons.
“I will ensure that it is repeated in all versions of the NHS planning framework while I am the secretary of state.”
Yvette Cooper says plans for cot cams in neonatal units to be ‘urgently’ developed
The health secretary said she has asked officials to develop plans to install “cot cams” in neonatal units.
She told the House of Commons:
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 aren’t able to be with them in person.
The government takes the recommendations from the Thirlwall inquiry “very seriously”, Cooper added.
Cooper says she is ‘profoundly sorry’ for failures set out in report
Health secretary Yvette Cooper has told the Commons she is “profoundly sorry” for the failures set out in the Thirlwall Inquiry report, which was prompted by Lucy Letby’s crimes.
In a statement, Cooper said:
Let me address the issues for the families and the parents directly, because 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, and for the failures to keep their babies safe. Our responsibility now is to act.
She added that officials have been instructed to develop plans to fit “cot cams” in neonatal units, following a recommendation in the report.
Ciarán Devane, chief executive of the NHS Alliance, said health leaders across the NHS “will share in the widespread sense of dismay and deep sorrow over the events that unfolded at the Countess of Chester hospital, and the determination to improve safety and accountability in the NHS”.
He added:
They will recognise the inquiry’s strong words on the upheaval caused by successive reorganisations, the complex regulatory landscape, staff shortages, unacceptable ‘revolving door’ appointments and the inadequacies of under-funded NHS IT systems.
They will welcome the call to strengthen managerial accountability while also implementing better training and support for managers.
We look forward to working with the government as it aims to develop a regulatory system for managers that is effective, equitable and fair, and that is fit for purpose for its intended aims.
Tamlin Bolton, from Irwin Mitchell who represents seven children harmed by Lucy Letby, said: “Lady Thirlwall’s report paints a damning picture of what happens when concerns over patient safety are not listened to and acted on.
“In her own words, a dispiriting and at times shocking account of multiple and repeated failings by organisation and individuals.”
She said there had been direct and frank criticism of all those at senior management level and a description of a chief executive officer “with an intention throughout to stall or obstruct a police investigation”.
She said:
The families recognise that no system can guarantee that deliberate criminal acts will never occur. But when concerns are raised about patient safety, they must be listened to, investigated properly and acted on without delay.
The report today and the criticisms and failings highlighted in it cannot be the end of the matter. The families deserve more than expressions of regret and promises of change.
She said translating the inquiry’s recommendations into “meaningful and lasting change” would honour the children at the centre of the inquiry.
In a joint statement, Sue Hodkinson, Alison Kelly, Ian Harvey and Tony Chambers, the former senior managers at the Countess of Chester Hospital, said: “We are carefully reviewing the Thirlwall report and its recommendations.
“Given that there are a number of investigations under way, and that the work of the Criminal Cases Review Commission has not yet completed, it would be inappropriate for us to offer any further comment at this time.
“Our thoughts remain with the families affected by the tragic events that took place at the Countess of Chester Hospital.”
Dr Toli Onon, who joined the CQC as chief inspector of hospitals last year, said it was sorry for shortfalls in the evidence it could present to the inquiry.
She said:
We are truly sorry for the fact that there were significant shortfalls in CQC’s document management that impacted the evidence we were able to provide to the inquiry.
An independent external review of our information and records management practices has since been undertaken, and learning from that review is being used to improve CQC’s information management practices and document management systems.
The Thirlwall report makes very clear the need to focus on our core purpose and develop teams that work to achieve that purpose.
We are absolutely committed to improving how we work with others to keep people safe and improve care, how we use information to assess quality, identify risk and take appropriate action, and how we give people assurance about the services they rely on.
We will ensure the learning from this report is embedded in the turnaround process CQC is currently engaged in. We are committed to working with the Department of Health and Social Care and wider system partners to play our part in taking forward the recommendations set out by Lady Justice Thirlwall and her team.
The Care Quality Commission (CQC), which is in charge of inspecting hospitals in England, has admitted some of its inquiries and record-keeping fell short when it came to the Countess of Chester Hospital and the Thirlwall Inquiry.
Dr Toli Onon, CQC’s chief inspector of hospitals, said in a statement:
My deepest sympathies go out to the families who continue to suffer as a result of these horrifying crimes. Everyone who has a role in delivering, leading or regulating healthcare services must actively consider the findings of this report to help prevent another situation where premeditated harm goes undetected.
Our focus now must be on what additional safeguards need to be put in place to ensure that patients are better protected from this kind of harm. Our 2016 inspection of Countess of Chester Hospital did not identify an increase in neonatal mortality. Crucial information was not shared by the hospital – however, what is also very clear is that we as the regulator, did not take an approach which was sufficiently investigative and inquiring.
We have learnt from this and our assessment approach has been significantly strengthened since that point in time.
She added:
We now employ a more probing and evidence-led assessment model, with greater emphasis on clinical expertise. We have also made changes to our assessment approach to improve oversight of neonatal services.
Neonatal care is now inspected as a standalone service aligned to maternity, with relevant neonatal data presented to inspectors separately from data for other services – ensuring the whole team has clear and direct access to all intelligence as part of their assessment.
We have added to the range of mortality data sets that we review and are in discussion with NHS England about accessing additional data they hold, to allow more active tracking of mortality.
Afternoon summary
Here is a quick summary of the main findings of the report:
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Three babies might have survived and seven others could have been protected if hospital bosses and doctors had taken action over concerns about the nurse Lucy Letby, the Thirlwall inquiry found.
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The report found a “complete failure” in safeguarding to protect babies on the neonatal unit at the Countess of Chester hospital, where Letby worked.
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The inquiry, which was chaired by Lady Justice Thirlwall, also found parents were “kept in the dark” for years about what happened to their babies and the concerns they may have been deliberately harmed.
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Thirlwall said the report described dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals of safeguarding.
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A total of 14 recommendations were made in the report, including the fitting of baby monitors in all cots and incubators in neonatal units and CCTV cameras focused on insulin storage fridges.
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But the inquiry chair said she was not reassured that ministers would act on her recommendations after the abolition of NHS England and little clarity on which body would take responsibility.
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The health secretary, Yvette Cooper, is due to make an oral statement on the inquiry’s findings at 3pm.
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Letby, who maintains her innocence, is serving 15 whole-life terms for the murders of seven babies and attempted murders of seven others by various means between June 2015 and June 2016. The 36-year-old was twice denied permission to appeal against her convictions in 2024.
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The Criminal Cases Review Commission is considering evidence presented on her behalf by an international panel of medics who claim poor medical care and natural causes were the reasons for the babies collapsing.
‘This cannot be allowed to happen again,’ lawyer representing families says
Meanwhile, Richard Scorer, head of abuse law and public Inquiries at Slater and Gordon, who acts for three of the affected families, said:
The families I represent were looking for a clear analysis of what went wrong and strong recommendations to prevent this happening again.
The report delivers both. Lady Thirlwall is clear that the police should have been informed in August 2015, not 18 months later, and that hospital managers misled the families and the trust failed in its duty of candour.
My clients welcome the recommendations around CCTV, access to insulin, strengthening of the duty of candour to include hospital managers and barring of managers guilty of incompetence and misconduct.
The challenge now is to ensure that recommendations are implemented without delay. Far too often public inquiry recommendations are left to gather dust. This cannot be allowed to happen again.
Reacting to the publication of the report, Lucy Letby’s barrister, Mark McDonald, said it was “particularly regrettable” that his client could not participate in the inquiry.
In a statement, he said:
This inquiry has proceeded on the wrong premise, and it follows that this has inevitably affected the report as a whole. Errors made at trial have in important respects been repeated in the inquiry’s conclusions, and the alternative narrative identified by nearly 30 internationally renowned experts has not been properly considered.
I do however wholeheartedly agree with the introduction of CCTV in all neonatal units and cots – this would have significantly impacted the outcome at trial and we would not be where we are today with an innocent woman in prison for crimes she did not commit.
It is particularly regrettable that Lucy’s application to participate in the inquiry was rejected. Had she been represented, the inquiry would have been able to hear an alternative account – one that said that insulin results were unreliable, one that said the deaths did not stop when Lucy left the unit and one which, in the view of international experts, provides a fundamentally different and more accurate understanding of what happened.
Here are some of the images being sent to us from outside Liverpool Town Hall, where the Thirlwall inquiry has been held:
Josh Halliday
The Guardian’s north of England editor, Josh Halliday, has been reporting from Liverpool Town Hall, where the report was delivered:
As Thirlwall delivered her remarks, a group of about 30 protestors held placards and chanted “No babies were murdered” outside Liverpool town hall.
Nicky Robinson, a retired nurse, said she deliberated about whether to attend the demonstration as she was concerned about upsetting the families of the babies.
However, the 59-year-old said she passionately believed that Letby had been made a “fall guy” and that “the truth must come out about how these children died”.
“I don’t want to upset any families but Lucy deserves a fair trial. I’ve worked with bereaved families and it’s terrible but the truth must come out about how these children died.”
Another protestor, Bernie Rowlands, had travelled nearly 200 miles from Gloucestershire to the demonstration. He had followed the case from the beginning because he used to live near Hereford, where Letby grew up.
Rowlands, 64, said: “I feel desperately sorry for (the families of the babies) but I would say that the police and certain newspapers have made their grief continue by pushing the guilty narrative. There’s no evidence here as far as I’m concerned.”
Lady Justice Thirlwall said work done by the inquiry showed a “very high number of recommendations” had been accepted by government but not yet implemented.
She said: “If my recommendations are going to be implemented in a timely fashion so that the safety of babies and others in hospital is secured there must be an energetic and determined approach to implementation.”
At the end of her statement at Liverpool Town Hall, she thanked parents of Letby’s victims for contributing so “generously and thoughtfully” to the inquiry.
She added:
They have borne this exercise with dignity and fortitude. It is my hope that their work, their evidence, the recommendations of the inquiry which draw on the evidence of many contributors will mean that others do not have to live through experiences like theirs.
We are expecting the health secretary, Yvette Cooper, to deliver an oral statement reacting to the inquiry’s findings at 3pm. She may lay out the government’s position on some of the report’s recommendations then.
What were some of the recommendations made in the report?
Jamie Grierson
A total of 14 recommendations have been made in the Thirlwall inquiry report – including the fitting of baby monitors in all cots and incubators in neonatal units and CCTV cameras focused on insulin storage fridges.
The recommendations follow the conclusions made by Thirlwall, the inquiry chair, who said the collapse and deaths of some babies could have been avoided if safeguarding practices had been followed.
She said baby monitors would ensure parents could observe their babies “remotely at any time” – adding that NHS England should “set out a roadmap” for how it could be implemented by 31 March next year.
You can read the full list of recommendations here.
Families must not become ‘collateral damage’ in public argument on whether Letby is guilty, judge says
The judge highlights the dignity and bravery of the parents who gave evidence to the inquiry. The families cannot be named for legal reasons as a court order prohibits reporting of the identities of the surviving and dead children involved in the case.
She urged “everyone commenting on the events” at the hospital to “remind themselves that these are all real people who have suffered grievously” and “continue to suffer as a result of the unexpected collapses and or deaths of their babies”.
Their “dignity and courage should be respected by everyone”, she added, warning that the families should not become “collateral damage” in the public debate about whether Lucy Letby is guilty or not.
Parents ‘kept in the dark’ for years, judge says
Josh Halliday
The inquiry, which received evidence from nearly 400 witnesses, found that parents were “kept in the dark” for years about what happened to their babies and the concerns they may have been deliberately harmed. This was “reprehensible”, Thirlwall said.
Despite the concerns of senior doctors, the inquiry found that the hospital’s risk and patient safety department took no action until the end of June 2016, when two twin boys died unexpectedly. Thirlwall said the department “failed in its fundamental task to enhance patient safety”.
The inquiry chair accused hospital executives of overseeing “an exercise in spin” by downplaying the rise in deaths to the board of directors.
Their failure to contact police before April 2017 – nearly two years after the unexplained increase in deaths – suggested that protecting the hospital’s reputation was “prized more highly” than the doctors’ concerns, she found.
Lady Justice Thirlwall said she had considered if any of the babies’ collapses and deaths could have been prevented.
She said if insulin results relating to baby F had been acted upon at the time, contacting the police would have been unavoidable.
She said:
After the death of Baby I suspicions became clearer. If safeguarding action had been taken, Letby should have been moved from the neonatal unit at this point. This did not happen.
The collapses and deaths continued. At an important meeting in May 2016 safeguarding was not considered, and Letby remained on the ward. This should not have happened, and babies O and P should not have died.
Source: https://www.theguardian.com/uk-news/live/2026/sep/15/lucy-letby-thirlwall-inquiry-report-findings-published-latest-updates
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