Reports & recommendations
44 recommendations, each with the government response on the record. Filter by government response or delivery status.
Reports (1)
| Title | Volume | Publication Date | Recommendations | Links |
|---|---|---|---|---|
| Report of the Morecambe Bay Investigation | Final | 03 Mar 2015 | 44 |
Recommendations (44)
Admit problems and apologise to affected families
The University Hospitals of Morecambe Bay NHS Foundation Trust should formally admit the extent and nature of the problems that have previously occurred, and should apologise to those patients and relatives affected, not only for the avoidable damage caused but also for the length of time it has taken to bring them to light and the previous failures to act. This should begin immediately with the response to this Report.
In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, noting that action had been taken and that University Hospitals of Morecambe Bay NHS Foundation Trust entered the Maternity Safety Support Programme in 2021 (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found evidence of implementation, citing the department's July 2015 report stating that the trust had formally admitted the problems and apologised individually to families (Department of Health response, Jul 2015; The Thirlwall Inquiry legal team, May 2024).
Review clinical staff competencies
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the skills, knowledge, competencies and professional duties of care of all obstetric, paediatric, midwifery and neonatal nursing staff, and other staff caring for critically ill patients in anaesthetics and intensive and high dependency care, against all relevant guidance from professional and regulatory bodies. This review should be completed by June 2015, and identify requirements for additional training, development and, where necessary, a period of experience elsewhere.
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, stating that action taken in response had been noted (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team found in February 2026 that University Hospitals of Morecambe Bay NHS Foundation Trust had established an education, learning and development project following the investigation (The Thirlwall Inquiry legal team, Feb 2026). It reported that this project set explicit training expectations across women's and children's services and related teams, created a central training management system, and introduced preceptorship and leadership programmes (The Thirlwall Inquiry legal team, Feb 2026).
Deliver staff training and development plans
The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up plans to deliver the training and development of staff identified as a result of the review of maternity, neonatal and other staff, and should identify opportunities to broaden staff experience in other units, including by secondment and by supernumerary practice. These should be in place in time for June 2015.
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the Thirlwall Inquiry had noted action taken in response to the recommendation (DHSC and NHS England, Feb 2026). In its February 2026 review, the inquiry legal team found that University Hospitals of Morecambe Bay NHS Foundation Trust had put in place an education, learning, and development project by April 2016, establishing explicit training expectations, a central training management system, and leadership and preceptorship programmes (The Thirlwall Inquiry legal team, Feb 2026).
Establish continuing professional development requirements
Following completion of additional training or experience where necessary, the University Hospitals of Morecambe Bay NHS Foundation Trust should identify requirements for continuing professional development of staff and link this explicitly with professional requirements including revalidation. This should be completed by September 2015.
In commentary submitted in September 2024, the Department of Health and Social Care and NHS England stated that the recommendation was complete, recording that action taken had been noted (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team found that University Hospitals of Morecambe Bay NHS Foundation Trust had put in place the Kirkup Education Learning and Development Project by April 2016 (The Thirlwall Inquiry legal team, Feb 2026). It found that this project agreed explicit training expectations, developed a central training management system to monitor compliance, and introduced preceptorship and leadership development programmes (The Thirlwall Inquiry legal team, Feb 2026).
Promote effective multidisciplinary team-working
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and develop measures that will promote effective multidisciplinary team-working, in particular between paediatricians, obstetricians, midwives and neonatal staff. These measures should include, but not be limited to, joint training sessions, clinical, policy and management meetings and staff development activities. Attendance at designated events must be compulsory within terms of employment. These measures should be identified by April 2015 and begun by June 2015.
In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England classified the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response to it (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that the Trust had taken action to address the recommendation, noting the establishment of a Clinical Quality Project overseen by an Executive Nurse Director (The Thirlwall Inquiry legal team, May 2024).
Draw up maternity risk assessment protocol
The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who will carry out this assessment against which criteria; and how this will be discussed with pregnant women and families. The protocol should involve all relevant staff groups, including midwives, paediatricians, obstetricians and those in the receiving units within the region. The Trust should ensure that individual decisions on delivery are clearly recorded as part of the plan of care, including what risk factors may trigger escalation of care, and that all Trust staff are aware that they should not vary decisions without a documented risk assessment. This should be completed by June 2015.
In February 2026, DHSC and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). In May 2024, the inquiry's legal team found that the Trust had refreshed and standardised clinical guidance on antenatal and intrapartum risk assessments across its maternity units (The Thirlwall Inquiry legal team, May 2024). Previously, in June 2021, University Hospitals of Morecambe Bay NHS Foundation Trust reported that a review panel considered the recommendation would be fully met once a dedicated electronic patient record for maternity was introduced (University Hospitals of Morecambe Bay NHS Foundation Trust, Jun 2021).
Audit maternity and paediatric services
The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care operates without inflexible demarcations between professional groups. This should be in place by September 2015.
In commentary submitted in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented, citing earlier work by University Hospitals of Morecambe Bay NHS Foundation Trust to refresh and standardise risk assessment guidance across maternity units (The Thirlwall Inquiry legal team, May 2024). Previously, the Trust had reported in June 2021 that an internal review panel considered the recommendation would be fully met once a dedicated electronic patient record for maternity was introduced (University Hospitals of Morecambe Bay NHS Foundation Trust, Jun 2021).
Develop recruitment and retention strategy
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify a recruitment and retention strategy aimed at achieving a balanced and sustainable workforce with the requisite skills and experience. This should include, but not be limited to, seeking links with one or more other centre(s) to encourage development of specialist and/or academic practice whilst offering opportunities in generalist practice in the Trust; in addition, opportunities for flexible working to maximise the advantages of close proximity to South Lakeland should be sought. Development of the strategy should be completed by January 2016.
In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response to it (DHSC and NHS England, Feb 2026). In May 2024, that inquiry's legal team found that University Hospitals of Morecambe Bay NHS Foundation Trust had developed a recruitment and retention strategy across partner organisations and reviewed employment contracts to provide flexible working (The Thirlwall Inquiry legal team, May 2024).
Improve joint working between hospital sites
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify an approach to developing better joint working between its main hospital sites, including the development and operation of common policies, systems and standards. Whilst we do not believe that the introduction of extensive split-site responsibilities for clinical staff will do much other than lead to time wasted in travelling, we do consider that, as part of this approach, flexibility should be built into working responsibilities to provide temporary solutions to short-term staffing problems. This approach should be begun by September 2015.
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented and closed, recording that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been clearly implemented, citing the Trust's development of cross-bay obstetric and midwifery guidelines and Bay-wide procedural documents (The Thirlwall Inquiry legal team, May 2024).
Establish partner Trust buddying arrangement
The University Hospitals of Morecambe Bay NHS Foundation Trust should seek to forge links with a partner Trust, so that both can benefit from opportunities for learning, mentoring, secondment, staff development and sharing approaches to problems. This arrangement is promoted and sometimes facilitated by Monitor as 'buddying' and we endorse the approach under these circumstances. This could involve the same centre identified as part of the recruitment and retention strategy. If a suitable partner is forthcoming, this arrangement should be begun by September 2015.
In February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented, stating that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the inquiry's legal team found that the measure had been clearly implemented, citing an April 2016 report in which the Trust confirmed strategic partnerships with Central Manchester University Hospitals NHS Foundation Trust and Lancashire Teaching Hospitals NHS Foundation Trust (The Thirlwall Inquiry legal team, May 2024).
Raise awareness of incident reporting and duty of candour
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with the duty of candour of professional staff, and incorporate into the programme compliance with the refreshed policy. This should be begun with maternity staff by April 2015 and rolled out to other staff by April 2016.
In September 2024, in commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented and closed, noting that the Thirlwall Inquiry had recorded action taken (DHSC and NHS England, Feb 2026). Previously, in May 2024, the inquiry legal team found that the measure had been clearly implemented, citing a July 2015 report in which the department noted that the Trust had begun an awareness programme with maternity staff (Department of Health response, Jul 2015; The Thirlwall Inquiry legal team, May 2024).
Review incident investigation structures
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning from incidents, identifying any residual conflicts of interest and requirements for additional training. The Trust should ensure that robust documentation is used, based on a recognised system, and that Board reports include details of how services have been improved in response. The review should include the provision of appropriate arrangements for staff debriefing and support following a serious incident. This should be begun with maternity units by April 2015 and rolled out across the Trust by April 2016.
In commentary submitted in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). In May 2024, the inquiry's legal team noted that University Hospitals of Morecambe Bay NHS Foundation Trust had begun reviewing incident investigation procedures with maternity staff (The Thirlwall Inquiry legal team, May 2024). The Trust had previously stated in June 2021 that a review panel would consider the recommendation fully met once action plans were complete and audits showed sustained improvement, which was due by June 2022 (University Hospitals of Morecambe Bay NHS Foundation Trust, Jun 2021).
Improve complaints handling
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in responding to complaints, and introduce measures to promote the use of complaints as a source of improvement and reduce defensive 'closed' responses to complainants. The Trust should increase public and patient involvement in resolving complaints, in the case of maternity services through the Maternity Services Liaison Committee. This should be completed, and the improvements demonstrated at an open Board meeting, by December 2015.
In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented, stating that the Thirlwall Inquiry had noted action taken in response to it (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been implemented, citing a 2016 Trust report that confirmed complaints procedures had been aligned with ombudsman guidelines, case officers had been assigned to liaise with complainants, and regular audits had been introduced (The Thirlwall Inquiry legal team, May 2024).
Review clinical leadership arrangements
The University Hospitals of Morecambe Bay NHS Foundation Trust should review arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure that the right people are in place with appropriate skills and support. The Trust has implemented change at executive level, but this needs to be carried through to the levels below. All staff with defined responsibilities for clinical leadership should show evidence of attendance at appropriate training and development events. This review should be commenced by April 2015.
In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as completed, stating that action taken had been noted (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found evidence that the recommendation had been clearly implemented, citing earlier reporting (The Thirlwall Inquiry legal team, May 2024). The department had previously reported in July 2015 that University Hospitals of Morecambe Bay NHS Foundation Trust had reviewed clinical leadership across obstetrics, paediatrics and midwifery (Department of Health response, Jul 2015).
Continue governance systems work
The University Hospitals of Morecambe Bay NHS Foundation Trust should continue to prioritise the work commenced in response to the review of governance systems already carried out, including clinical governance, so that the Board has adequate assurance of the quality of care provided by the Trust's services. This work is already underway with the facilitation of Monitor, and we would not seek to vary or add to it, which would serve only to detract from implementation. We do, however, recommend that a full audit of implementation be undertaken before this is signed off as completed.
In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, noting that the Thirlwall Inquiry had recognized action taken in response (DHSC and NHS England, Feb 2026). The inquiry's legal team found in May 2024 that University Hospitals of Morecambe Bay NHS Foundation Trust had standardized its audit process and that an internal audit programme had reviewed governance processes during 2014 and 2015 (The Thirlwall Inquiry legal team, May 2024).
Clarify manager quality responsibilities
As part of the governance systems work, we consider that the University Hospitals of Morecambe Bay NHS Foundation Trust should ensure that middle managers, senior managers and non-executives have the requisite clarity over roles and responsibilities in relation to quality, and it should provide appropriate guidance and where necessary training. This should be completed by December 2015.
In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the inquiry legal team found that the recommendation was implemented, citing an April 2016 trust update showing that non-executive directors chaired sub-board assurance committees and annual mandatory risk management training had been established (The Thirlwall Inquiry legal team, May 2024).
Improve Furness General Hospital delivery suite
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify options, with a view to implementation as soon as practicable, to improve the physical environment of the delivery suite at Furness General Hospital, including particularly access to operating theatres, an improved ability to observe and respond to all women in labour and en suite facilities; arrangements for post-operative care of women also need to be reviewed. Plans should be in place by December 2015 and completed by December 2017.
In February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). In May 2024, that inquiry's legal team found that the recommendation had been clearly implemented, citing University Hospitals of Morecambe Bay NHS Foundation Trust's 2016 plans for a new build with handover scheduled for November 2017 (The Thirlwall Inquiry legal team, May 2024).
Ensure external oversight of implementation
All of the previous recommendations should be implemented with the involvement of Clinical Commissioning Groups, and where necessary, the Care Quality Commission and Monitor. In the particular circumstances surrounding the University Hospitals of Morecambe Bay NHS Foundation Trust, NHS England should oversee the process, provide the necessary support, and ensure that all parties remain committed to the outcome, through an agreed plan with the Care Quality Commission, Monitor and the Clinical Commissioning Groups.
In September 2024 commentary published in February 2026, NHS England and the Department of Health and Social Care recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response to it (DHSC and NHS England, Feb 2026). Earlier, that inquiry's legal team found in May 2024 that the recommendation had been clearly implemented, citing the department's July 2015 response which confirmed that the hospital trust was working closely with the Care Quality Commission and Monitor (Department of Health response, Jul 2015; The Thirlwall Inquiry legal team, May 2024).
Professional bodies review conduct of registrants
In light of the evidence we have heard during the Investigation, we consider that the professional regulatory bodies should review the findings of this Report in detail with a view to investigating further the conduct of registrants involved in the care of patients during the time period of this Investigation. Action: the General Medical Council, the Nursing and Midwifery Council.
The Department of Health and Social Care and NHS England reported in February 2026 that the General Medical Council and the Nursing and Midwifery Council had completed their investigations into the conduct of the registrants involved (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented, pointing to the regulators' review of the investigation findings and commitment to take appropriate action (The Thirlwall Inquiry legal team, May 2024).
National review of maternity care in challenging circumstances
There should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas that are rural, difficult to recruit to, or isolated. This should identify the requirements to sustain safe services under these conditions. In conjunction, a national protocol should be drawn up that defines the types of unit required in different settings and the levels of care that it is appropriate to offer in them. Action: NHS England, the Care Quality Commission, the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of Paediatrics and Child Health, the National Institute for Health and Care Excellence.
In February 2026, the Department of Health and Social Care and NHS England stated that because the 2016 Better Births review showed a single model was unfeasible for rural units, reviewing requirements as proposed was not appropriate (DHSC and NHS England, Feb 2026). They noted that work had instead progressed through a neonatal care review and the 2023 Three Year Delivery Plan for Maternity and Neonatal Services (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found evidence that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).
Consider extending review to other rural services
The challenge of providing healthcare in areas that are rural, difficult to recruit to or isolated is not restricted to maternity care and paediatrics. We recommend that NHS England consider the wisdom of extending the review of requirements to sustain safe provision to other services. This is an area lacking in good-quality research yet it affects many regions of England, Wales and Scotland. This should be seen as providing an opportunity to develop and promote a positive way of working in remote and rural environments. Action: NHS England.
In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England stated that it had concluded "it would not be appropriate to review requirements in the way proposed" because local variations made a single service model unfeasible (DHSC and NHS England, Feb 2026). It noted that work remained underway within pilot integrated care systems on rural workforce transformation, alongside funding formula adjustments to support remote providers (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been completed based on care models and support regimes established by the government (The Thirlwall Inquiry legal team, May 2024).
Recognise educational opportunities in smaller units
We believe that the educational opportunities afforded by smaller units, particularly in delivering a broad range of care with a high personal level of responsibility, have been insufficiently recognised and exploited. We recommend that a review be carried out of the opportunities and challenges to assist such units in promoting services and the benefits to larger units of linking with them. Action: Health Education England, the Royal College of Obstetricians and Gynaecologists, the Royal College of Paediatrics and Child Health, the Royal College of Midwives.
In commentary published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team found in its February 2026 review that Health Education England published the findings of its review in spring 2016, which recommended that all trusts and learning education providers continue to support clinical education and training (The Thirlwall Inquiry legal team, Feb 2026).
Clear standards for incident reporting in maternity
Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and intrapartum stillbirths and unexpected neonatal deaths. We believe that there is a strong case to include a requirement that investigation of these incidents be subject to a standardised process, which includes input from and feedback to families, and independent, multidisciplinary peer review, and should certainly be framed to exclude conflicts of interest between staff. We recommend that this build on national work already begun on how such a process would work. Action: the Care Quality Commission, NHS England, the Department of Health.
In September 2024, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, citing the Patient Safety Incident Response Framework, the Maternity and Newborn Safety Investigations Programme, and the national Perinatal Mortality Review Tool (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team likewise found that the recommendation had been clearly implemented, noting the creation of the Healthcare Safety Investigation Branch and the introduction of the perinatal review tool (The Thirlwall Inquiry legal team, Feb 2026).
Involve patients and relatives in incident investigation
We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious incidents, both to provide evidence that may otherwise be lacking and to receive personal feedback on the results. Action: the Care Quality Commission, NHS England.
In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that work remained ongoing, highlighting national guidance on patient involvement and the rollout of the Patient Safety Incident Response Framework (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team recorded in the same review that the recommendation had been met, citing the statutory duty of candour and the new incident framework (The Thirlwall Inquiry legal team, Feb 2026). The department noted that a government review of the statutory duty of candour was still underway, alongside planned legislation to establish a duty of candour for public servants (DHSC and NHS England, Feb 2026).
Duty to report external investigation findings
We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the operation of the Trust, including prompt notification of relevant external bodies such as the Care Quality Commission and Monitor. The Care Quality Commission should develop a system to disseminate learning from investigations to other Trusts. Action: the Department of Health, the Care Quality Commission.
In commentary submitted in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England stated that an updated 2022 review framework strengthened information sharing with regulators regarding patient safety risks (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted existing trust reporting requirements and national safety investigation functions (The Thirlwall Inquiry legal team, May 2024). The department had previously reported in March 2020 that the Care Quality Commission did not have a system for disseminating learning to other trusts, although local networks helped share findings (Nadine Dorries, Mar 2020).
Clear national whistleblowing policy
We commend the introduction of a clear national policy on whistleblowing. As well as protecting the interests of whistleblowers, we recommend that this is implemented in a way that ensures that a systematic and proportionate response is made by Trusts to concerns identified. Action: the Department of Health.
The Investigation recommended introducing a clear national whistleblowing policy for trusts responding to concerns. In commentary of September 2024, published in February 2026, the Department of Health and Social Care and National Health Service (NHS) England stated that the Thirlwall Inquiry had noted action taken in response to this recommendation (DHSC and NHS England, Feb 2026). In September 2026, the Inquiry reported that "the move towards less national oversight, with the abolition of the NGO, is worrying in this context" (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026).
Professional duty to report concerns
Professional regulatory bodies should clarify and reinforce the duty of professional staff to report concerns about clinical services, particularly where these relate to patient safety, and the mechanism to do so. Failure to report concerns should be regarded as a lapse from professional standards. Action: the General Medical Council, the Nursing and Midwifery Council, the Professional Standards Authority for Health and Social Care.
In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that implementation was ongoing, noting that joint duty of candour guidance was updated in 2019 and the General Medical Council updated its Good Medical Practice standards in January 2024 to require doctors to report concerns promptly (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that although online records showed an update letter sent to the Secretary of State, a complete report of Sir Bruce Keogh's review of professional codes could not be found (The Thirlwall Inquiry legal team, May 2024).
National standards for clinical leads
Clear national standards should be drawn up setting out the professional duties and expectations of clinical leads at all levels, including, but not limited to, clinical directors, clinical leads, heads of service, medical directors, nurse directors. Trusts should provide evidence to the Care Quality Commission, as part of their processes, of appropriate policies and training to ensure that standards are met. Action: NHS England, the Care Quality Commission, the General Medical Council, the Nursing and Midwifery Council, all Trusts.
In September 2024, the Department of Health and Social Care and NHS England reported that clinical leadership duties were addressed through professional regulatory guidance, trust inspections, and a February 2024 board competency framework (DHSC and NHS England, Feb 2026). In that same update, they stated that the Care Quality Commission was developing a new assessment framework, while initiatives to widen leadership development across all career stages remained underway (DHSC and NHS England, Feb 2026).
Standards for manager quality responsibilities
Clear national standards should be drawn up setting out the responsibilities for clinical quality of other managers, including executive directors, middle managers and non-executives. All Trusts should provide evidence to the Care Quality Commission, as part of their processes, of appropriate policies and training to ensure that standards are met. Action: NHS England, the Care Quality Commission, all Trusts.
In February 2026, the Department of Health and Social Care and NHS England reported that the Board Leadership Competency Framework and Our Leadership Way outline standards for leaders, with the Care Quality Commission assessing these areas during inspections (DHSC and NHS England, Feb 2026). They noted that initiatives to widen leadership development for managers at all career stages and work responding to the Messenger Review were still underway (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that although Sir Bruce Keogh had sent an update letter regarding his review of professional codes, a complete report of his assessment could not be found (The Thirlwall Inquiry legal team, May 2024).
National protocol on duties relating to inquests
A national protocol should be drawn up setting out the duties of all Trusts and their staff in relation to inquests. This should include, but not be limited to, the avoidance of attempts to 'fend off' inquests, a mandatory requirement not to coach staff or provide 'model answers', the need to avoid collusion between staff on lines to take, and the inappropriateness of relying on coronial processes or expert opinions provided to coroners to substitute for incident investigation. Action: NHS England, the Care Quality Commission.
In commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the government has not introduced a national protocol, explaining that existing legislation and professional codes remove the need for one (DHSC and NHS England, Feb 2026). They reported that inquest duties were instead addressed through provider reminders, regulator guidance, and the rollout of medical examiners in September 2024 (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that it could identify no follow-up to the department's initial commitment to consider an additional protocol (The Thirlwall Inquiry legal team, May 2024).
Fundamental review of NHS complaints system
The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it was not within our remit to examine the operation of the NHS complaints system nationally, both the nature of the failures and persistent comment from elsewhere lead us to suppose that this is not unique to this Trust. We believe that a fundamental review of the NHS complaints system is required, with particular reference to strengthening local resolution and improving its timeliness, introducing external scrutiny of local resolution and reducing reliance on the Parliamentary and Health Service Ombudsman to intervene in unresolved complaints. Action: the Department of Health, NHS England, the Care Quality Commission, the Parliamentary and Health Service Ombudsman.
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the department did not take forward a fundamental review and "therefore this recommendation was not implemented", noting that the Parliamentary and Health Service Ombudsman had instead issued complaint standards in 2022 (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team recorded in May 2024 that the department had accepted the recommendation in principle in 2015 but maintained that another review would not help (The Thirlwall Inquiry legal team, May 2024).
Reform Local Supervising Authority for midwives
The Local Supervising Authority system for midwives was ineffectual at detecting manifest problems at the University Hospitals of Morecambe Bay NHS Foundation Trust, not only in individual failures of care but also with the systems to investigate them. As with complaints, our remit was not to examine the operation of the system nationally; however, the nature of the failures and the recent King's Fund review (Midwifery regulation in the United Kingdom) lead us to suppose that this is not unique to this Trust, although there were specific problems there that exacerbated the more systematic concern. We believe that an urgent response is required to the King's Fund findings, with effective reform of the system. Action: the Department of Health, NHS England, the Nursing and Midwifery Council.
In commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented and closed, explaining that the Nursing and Midwifery (Amendment) Order 2017 separated supervision from regulation and that a new non-statutory supervision model, A-EQUIP, had been rolled out across the UK (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).
CQC and Monitor coordination
We considered carefully the effectiveness of separating organisationally the regulation of quality by the Care Quality Commission from the regulation of finance and performance by Monitor, given the close inter-relationship between Trust decisions in each area. However, we were persuaded that there is more to be gained than lost by keeping regulation separated in this way, not least that decisions on safety are not perceived to be biased by their financial implications. The close links, however, require a carefully coordinated approach, and we recommend that the organisations draw up a memorandum of understanding specifying roles, relationships and communication. Action: Monitor, the Care Quality Commission, the Department of Health.
In February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented and closed, confirming that the February 2015 memorandum of understanding between Monitor and the Care Quality Commission still stood and that an information sharing agreement was planned (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found evidence that the measure had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).
CQC and PHSO memorandum of understanding
The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for concern, in particular the breakdown in communication between the Care Quality Commission and the Parliamentary and Health Service Ombudsman over necessary action and follow-up. We recommend that a memorandum of understanding be drawn up clearly specifying roles, responsibilities, communication and follow-up, including explicitly agreed actions where issues overlap. Action: the Care Quality Commission, the Parliamentary and Health Service Ombudsman.
In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, stating that arrangements, including a memorandum of understanding, are in place between the Care Quality Commission and the Parliamentary and Health Service Ombudsman (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).
Clarify oversight responsibilities
The division of responsibilities between the Care Quality Commission and other parts of the NHS for oversight of service quality and the implementation of measures to correct patient safety failures was not clear, and we are concerned that potential ambiguity persists. We recommend that NHS England draw up a protocol that clearly sets out the responsibilities for all parts of the oversight system, including itself, in conjunction with the other relevant bodies; the starting point should be that one body, the Care Quality Commission, takes prime responsibility. Action: the Care Quality Commission, NHS England, Monitor, the Department of Health.
In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed (DHSC and NHS England, Feb 2026). They stated that the National Quality Board framework clarifies governance arrangements and brings partners, including the Care Quality Commission, together in System Quality Groups to share intelligence on quality and risk (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team recorded that the department had accepted the proposal in principle, citing its commitments to improve oversight through the board and consolidate patient safety leadership (The Thirlwall Inquiry legal team, May 2024).
Impact assessment of policy changes
The cumulative impact of new policies and processes, particularly the perceived pressure to achieve Foundation Trust status, together with organisational reconfiguration, placed significant pressure on the management capacity of the University Hospitals of Morecambe Bay NHS Foundation Trust to deliver against changing requirements whilst maintaining day-to-day needs, including safeguarding patient safety. Whilst we do not absolve Trusts from responsibility for prioritising limited capability safely and effectively, we recommend that the Department of Health should review how it carries out impact assessments of new policies to identify the risks as well as the resources and time required. Action: the Department of Health.
The Department of Health and Social Care and NHS England stated in September 2024 commentary published in February 2026 that the recommendation had been implemented, explaining that an internal Senior Review Committee evaluates all potential policy impacts, including risks of perverse incentives, alongside extensive quality assurance (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been clearly implemented, citing reforms to the Foundation Trust application process and regulatory oversight (The Thirlwall Inquiry legal team, May 2024).
Protocol for organisational change transitions
Organisational change that alters or transfers responsibilities and accountability carries significant risk, which can be mitigated only if well managed. We recommend that an explicit protocol be drawn up setting out how such processes will be managed in future. This must include systems to secure retention of both electronic and paper documents against future need, as well as ensuring a clearly defined transition of responsibilities and accountability. Action: the Department of Health.
The Department of Health and Social Care and NHS England reported in February 2026 that the recommendation was implemented and closed, pointing to an updated Records Management Code of Practice from 2021, a revised departmental Information Management Policy from 2018, and published guidance addressing transfer risks during reorganisations (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).
Improve perinatal mortality recording
Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units rely inappropriately on headline mortality figures to reassure others that all is well. We recommend that recording systems are reviewed and plans brought forward to improve systematic recording and tracking of perinatal deaths. This should build on the work of national audits such as MBRRACE-UK, and include the provision of comparative information to Trusts. Action: NHS England.
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, noting that perinatal deaths must be reported to MBRRACE-UK within 30 days by place of birth and that a review tool had been adopted across all English trusts (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).
Implement medical examiner system
There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith in her review of the Shipman deaths, but is in our view no less applicable to maternal and perinatal deaths, and should have raised concerns in the University Hospitals of Morecambe Bay NHS Foundation Trust before they eventually became evident. Legislative preparations have already been made to implement a system based on medical examiners, as effectively used in other countries, and pilot schemes have apparently proved effective. We cannot understand why this has not already been implemented in full, and recommend that steps are taken to do so without delay. Action: the Department of Health.
The Investigation recommended the prompt, full implementation of a medical examiner system. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that a statutory medical examiner system rolled out across England and Wales on 9 September 2024 to review all non-coronial deaths, including neonatal deaths (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry reported in September 2026 that the full statutory scheme was operational from that date (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026). Previously, in March 2024, the Expert Panel of the House of Commons Health and Social Care Committee found the recommendation had not been fully met, observing that an extended remit for medical examiners to scrutinise perinatal and maternal deaths was not in place (House of Commons Health and Social Care Committee, Mar 2024; House of Commons Health and Social Care Committee, Mar 2024).
Extend medical examiners to stillbirths
Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, thereby ensuring that appropriate recommendations are made to coroners concerning the occasional need for inquests in individual cases, including deaths following neonatal transfer. Action: the Department of Health.
The Investigation recommended extending the medical examiner system to review stillbirths and neonatal deaths. The Department of Health and Social Care and NHS England stated in commentary of September 2024, published in February 2026, that the recommendation had not been taken forward (DHSC and NHS England, Feb 2026). They explained that while the statutory medical examiner system was introduced in September 2024 for non-coronial deaths, stillbirths cannot be included because stillborn babies are not legally classified as having died (DHSC and NHS England, Feb 2026). In June 2026, Baroness Levitt for the Ministry of Justice stated that the government will consider next steps on coronial investigations of stillbirths after an independent investigation into maternity care led by Baroness Amos reports (Baroness Levitt, Jun 2026).
Guidance for external service reviews
We were concerned by the ad hoc nature and variable quality of the numerous external reviews of services that were carried out at the University Hospitals of Morecambe Bay NHS Foundation Trust. We recommend that systematic guidance be drawn up setting out an appropriate framework for external reviews and professional responsibilities in undertaking them. Action: the Academy of Medical Royal Colleges, the Royal College of Nursing, the Royal College of Midwives.
In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, following the Academy of Medical Royal Colleges publishing an updated framework for invited reviews in March 2022 (Academy of Medical Royal Colleges, Mar 2022; DHSC and NHS England, Feb 2026). They stated that the guidance provides operating principles for professional bodies conducting reviews across healthcare organisations and should improve the escalation of issues and disclosure to regulators (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).
Register external reviews with CQC
We further recommend that all external reviews of suspected service failures be registered with the Care Quality Commission and Monitor, and that the Care Quality Commission develops a system to collate learning from reviews and disseminate it to other Trusts. Action: the Care Quality Commission, Monitor.
The Department of Health and Social Care and NHS England stated in February 2026 that joint oversight groups are used with the Care Quality Commission to monitor provider risks, citing a 2022 framework requiring healthcare organisations to alert regulators to concerns found in reviews (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found no record of promised government proposals to mandate notifications, noting that online guidance asking trusts to disclose external reviews as a "matter of course" left it unclear whether compliance was a statutory requirement (The Thirlwall Inquiry legal team, May 2024).
Maintain focus on quality
We strongly endorse the emphasis placed on the quality of NHS services that began with the Darzi review, High Quality Care for All, and gathered importance with the response to the events at the Mid Staffordshire NHS Foundation Trust. Our findings confirm that this was necessary and must not be lost. We are concerned that the scale of recent NHS reconfiguration could result in new organisations and post-holders losing the focus on this priority. We recommend that the importance of putting quality first is re-emphasised and local arrangements reviewed to identify any need for personal or organisational development, including amongst clinical leadership in commissioning organisations. Action: NHS England, the Department of Health.
In February 2026, the Department of Health and Social Care and NHS England reported that implementation remained ongoing, highlighting a portfolio of National Quality Board guidance and tools developed to support Integrated Care Systems, including transition guidance and an updated framework for System Quality Groups (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).
Establish framework for future investigations
This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, and the legal basis for handling evidence. These obstacles were overcome, but the need to do this from scratch each time an investigation of this format is set up is unnecessarily time-consuming. We believe that this is an effective investigation format that is capable of getting to the bottom of significant service and organisational problems without the need for a much more expensive, time-consuming and disruptive public inquiry. This being so, we believe that there is considerable merit in establishing a proper framework, if necessary statutory, on which future investigations could be promptly established. This would include setting out the arrangements necessary to maintain independence and work effectively and efficiently, as well as clarifying responsibilities of current and former health service staff to cooperate. Action: the Department of Health.
The Department of Health and Social Care and NHS England reported in commentary published in February 2026 that the Health Services Safety Investigations Body was established in April 2023 with statutory processes for evidence handling and document access, alongside a national internal investigation framework (DHSC and NHS England, Feb 2026). Minister of State Karin Smyth similarly confirmed these arrangements in November 2024 (Karin Smyth, Nov 2024). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).