Response to the publication of the Thirlwall Inquiry report

Statement on the Inquiry report from Dr Rosie Benneyworth, Interim Chief Executive

"The publication of the Thirlwall Inquiry is a significant moment for patients, families, healthcare staff and everyone affected by the events it has examined. Our thoughts remain with the families whose lives have been profoundly impacted, and we echo Lady Justice Thirlwall’s tribute to their dignity and courage throughout the Inquiry.

“The Inquiry sets out a shocking catalogue of failings in relation to listening to concerns, safeguarding and effective governance and in neonatal safety. As we absorb its findings and recommendations in full, it is particularly important that Lady Justice Thirlwall has said ‘patient safety must be the top priority for all managers – indeed, for all people working in the NHS. All behaviour must be directed to that priority.’

“The report reiterates that high quality investigations are a vital part of safer care and makes the stark statement that if staff at Countess Chester had undergone effective investigation training then ‘some of the errors may have been avoided.’ Investigations should seek to understand systemic factors that contribute to harm and should engage with families throughout the process. They must be carried out by investigators with specialist skills and competencies and wholly supported by the leaders within their organisation. Crucially, the investigative processes must not compound harm experienced by patients and families. The Inquiry has recognised HSSIB’s value, particularly our expertise in investigation education. Training investigators across healthcare is a core part of our work, and is a priority for HSSIB over the coming year.

“It positive that the Inquiry has recognised the evidence I gave on the challenges of implementing recommendations and the distress it can cause to patients and families when action is not taken. Too many recommendations from inquiries, investigations and reviews are not effectively tracked, prioritised or implemented. We need stronger systems to oversee implementation and escalate when progress is not being made, and I will continue to advocate for this as an urgent matter. We know that recommendations can only improve safety if they lead to sustained change.

“Culture is critical to patient safety, and Thirlwall’s report was clear; staff at Countess of Chester felt fearful that they would face repercussions and disciplinary action for raising concerns about safety. Across our investigations, we continue to hear about environments where people do not feel able to speak up about concerns or where concerns raised by patients, families and staff are not consistently heard or acted upon. Psychological safety, transparency and effective teamwork are essential. Leaders at every level have a responsibility to create cultures where concerns can be raised without fear and where action follows when risks are identified. Thirlwall has reiterated the importance of HSSIB to encourage ‘honesty and candour’ and we welcome the recommendation that the PHSO will continue the functions of the National Guardians Office.

“Lastly, from our perspective, the report’s findings that there were serious failings in safeguarding and governance highlight that we need a more proactive approach to managing patient safety. Too often, healthcare identifies risks after harm has occurred. Safety management systems should help organisations identify, assess and manage risks before patients come to harm, supported by clear accountability, effective leadership and mechanisms to escalate concerns through organisations and across the wider NHS.

“Patients and families have already paid too high a price for the failures identified in the Inquiry. We can’t continue to diagnose safety problems in the NHS and then not act. There is a responsibility to ensure the lessons identified are translated into meaningful action. It must mark the beginning of a sustained effort to lead to real and lasting improvements in patient safety.”