The Government has announced a series of immediate actions to strengthen patient safety, safeguarding and accountability across the NHS, following the publication of Lady Justice Thirlwall's final report into events at the Countess of Chester Hospital.
The Inquiry identified significant failures in governance, leadership and safeguarding, concluding that multiple opportunities were missed to respond to concerns and protect vulnerable newborn babies from harm. Responding to the findings, Health and Social Care Secretary Yvette Cooper told Parliament that safeguarding must become a central priority across the NHS, and confirmed that ministers will act on the Inquiry's recommendations to help prevent similar failures in future.
While the Government carries out a detailed review of the full report, work has already begun on several measures intended to improve oversight, transparency and patient safety across maternity and neonatal services. Among the first steps announced are plans to introduce CCTV monitoring, including so called cot cams, in neonatal units, intended to enhance safety standards and provide reassurance for parents.
The Department is also developing new guidance covering the storage and use of insulin, alongside strengthened guidance for Medical Examiners responsible for reviewing neonatal deaths. In a further move aimed at improving accountability, ministers are progressing plans to regulate NHS managers through a barring scheme, which could prevent senior leaders who fail in their responsibilities from holding future leadership positions within the health service.
Support for bereaved families is also being strengthened through the continued national rollout of the Bereavement Care Pathway. All NHS trusts have now committed to implementing the programme, with the aim of ensuring more consistent support for families affected by neonatal loss.
To improve oversight of reforms across the sector, the Government will create a single national tracker to monitor recommendations arising from major maternity and neonatal reviews and inquiries. The stated aim is to provide greater transparency and ensure improvements are delivered consistently across the health service, rather than varying between individual trusts.
Speaking in Parliament, Cooper said the safety and care of babies, the safeguarding of every patient, and respect for families all went to the heart of the NHS's values. She acknowledged that the Inquiry recognised improvements had taken place in many areas since the events in question, including welcome changes at the Countess of Chester itself in services for women and children. However, she said the Inquiry was clear that further action was still required.
Cooper said she was taking the recommendations extremely seriously, and confirmed the Government would consider the report in full before setting out a complete response. She said safeguarding was everyone's business and must be everyone's priority, adding that concerns must be heard and acted upon, and that staff who speak up must be protected and taken seriously. She said she expected every leader, every board, every professional and every member of staff across the NHS to uphold their safeguarding responsibilities.
Cooper also confirmed that safeguarding principles will be embedded within the forthcoming Babies, Children and Young People's Modern Service Framework, describing this as reinforcing the Government's commitment to placing the safety and wellbeing of babies and children at the centre of healthcare delivery.
The announcement coincided with Cooper's first meeting as Chair of the Maternity and Neonatal Taskforce. The taskforce has been established to translate recommendations from the Ockenden and Amos reviews into a practical action plan for improving maternity and neonatal care across England, with that plan expected to be published later this year.
The Government has said it will publish a full response to all of Lady Justice Thirlwall's recommendations once the report has been considered in detail.
Cooper closed her statement by addressing the families directly affected by the failures identified in the report. She said the suffering endured by the babies and their families was impossible to comprehend, and that on behalf of the Government and the health service, she was profoundly sorry for the failures set out so clearly in the report, for the harm, distress and loss experienced by those families, and for the NHS's failure to keep babies safe.
