Public Inquiry Recommendations
Showing 4 of 1,955 recommendations from Thirlwall Inquiry
What these recommendations are about — Thirlwall Inquiry
Key themes in this inquiry:
Quality and safety oversight ·
No open learning culture ·
Staff policy awareness ·
Flawed mortality reviews ·
Staff training and development
.
Report published 2026 — 17 recommendations across this inquiry.
1
Accepted
Thirlwall Inquiry
(2026)
CCTV and monitoring
All cots and incubators in all neonatal units should be fitted with baby monitors (in-cot cameras with livestreaming video), so that parents can observe their baby remotely at any time. …
2
Accepted
Thirlwall Inquiry
(2026)
Insulin
i. Digital devices should be used to restrict access of insulin to authorised people and record access to insulin storage units. I acknowledge that steps are being taken to achieve …
3
Accepted
Thirlwall Inquiry
(2026)
Bereavement care
The National Bereavement Care Pathway for neonatal death should be implemented nationally and in all Trusts by 31 August 2027.
8
Accepted
Thirlwall Inquiry
(2026)
Sudden Unexpected Death in Infancy and Childhood (SUDIC)
i. NHS England must: a. Immediately inform all Trusts with a neonatal unit that the SUDIC process applies to the sudden and unexpected deaths of babies who have never left …