Inquiry chairwoman Lady Justice Thirlwall concluded that the deaths of some babies could have been avoided if standard safeguarding practices had been strictly followed.
Technology Upgrades and Remote Monitoring in Neonatal Units
Lady Justice Thirlwall stated that these devices would allow parents to observe their babies remotely at any time. The senior judge recommended that implementation costs be centrally managed and ring-fenced so hospitals can roll out the technology at speed. Additionally, the report called for digital devices to restrict insulin access to authorized personnel only, alongside systems to record all access to insulin units. Until these digital safeguards are fully installed, trusts must use CCTV cameras focused on storage fridges and cupboards, keeping recordings for at least 28 days.
Management Accountability and Safeguarding Protocols
The inquiry report recommends that NHS trusts demonstrate that senior manager reassignments to other trusts are not motivated by misconduct or a lack of capability. According to the inquiry findings, Lady Justice Thirlwall advised that all managers be bound by an individual duty of candor to patients and colleagues, supported by a formal code of conduct putting patients first. Trusts must also provide mandatory safeguarding training to all staff, including board members and non-executive directors, covering how to handle suspicions of deliberate harm. By March of next year, employee contracts must include a clear obligation to follow all relevant safeguarding guidance. Furthermore, NHS England must produce a one-page protocol directing managers to act immediately on suspicions, move accused personnel as a first step during investigations, and involve police.
Regulatory Oversight and Data Harmonization
To improve institutional oversight, Lady Justice Thirlwall urged the Department of Health and Social Care to consider establishing a panel of independent experts—including doctors, nurses, senior managers, and pathologists—to assist in proceedings where staff harm is suspected. The report also calls for a clear, timed route to harmonize computer systems across the NHS by December 2028, ensuring timely review and continuous monitoring of infant health data. Additionally, the Care Quality Commission should conduct unannounced inspections of hospital departments with instructions not to accept statements at face value, according to the inquiry findings.
