The Thirlwall Inquiry: Accountability and proportionality
The Report of the Thirlwall Inquiry into the convictions of Lucy Letby in September 2026 inevitably produced mixed responses. Perhaps standing out from the discussion of the report was the stated scepticism within it about whether the 17 recommendations made would in fact be implemented. Research by the legal team to the inquiry revealed that the vast majority of some 1,400 recommendations made by public inquiries over a period of 30 years had not been tracked or implemented.
The Letby inquiry spanned a period of three years and cost £19 million. If the recommendations are not going to be implemented, some basic questions about the role and value of public inquiries merit discussion.
In his engaging political diaries, Alan Clark recorded his view that he would not have joined with the Labour opposition in calling for a public inquiry into the Westland affair in 1986. Rather, in their position he would have said “fucking tell me now” (it does not appear that he actually expressed himself this way ever in the House of Commons).
It is not over-cynical to consider that a significant role of a public inquiry is to put a difficult issue into the political long grass. This is the opinion of Tom Kark KC, who recently described public inquiries as being costly “knee-jerk” reactions. He pointed out that with the ongoing style of revolving-doors ministerial government, there is real attraction to a current minister to order a public inquiry in the confident knowledge that some other minister will have to deal with the fallout. Mr Kark is a lawyer with considerable experience of public inquiries, having been Chief Counsel to the Mid Staffordshire inquiry, then the Chair of the Muckamore Abbey Hospital inquiry.
The Chilcot Inquiry: Delay, accountability and lessons learned
Perhaps the classic example of the political long grass would be the Chilcot inquiry into the invasion of Iraq in 2003. In fairness, this was not a knee-jerk reaction. It was not ordered until 2009, when the Prime Minister, Gordon Brown, bowed to growing public pressure over the war and its outcome. The inquiry did not report until July 2016. The report was 2.6 million words long. It concluded what was by that stage generally accepted that the attack on Iraq had been based on an assertion which was not supported by evidence, that is, that Saddam Hussein possessed weapons of mass destruction. Similarly, the inquiry found that the absence of any planning, or even thought, as to what would happen after the invasion had resulted in a prolonged period of chaos and misery for the citizens of Iraq. There was no discernible fallout from the report.
Why public inquiries still matter
Whilst not overly cynical, this view does ignore the real value of public inquiries. It is beyond question that the victims of major adverse events should have the opportunity to see the facts scrutinised in public and their concerns about the events leading to the disastrous outcome, addressed.
The problem is not therefore with public examination of facts, but rather with the making of recommendations.
The essential recurring issue with recommendations made by public inquiries is that they tend to make generally applicable suggestions when the inquiry itself has examined issues through a narrow lens, that is, the occurrence of specific events, at a specific time and at a specific location. A tendency to aggregate specific errors into findings of cultural or systemic issues can be seen across many inquiry reports not just public inquiries. Statements about culture and system can only accurately be made if there is an overall evaluation of the relevant trust, rather than seeing these issues through the prism of obvious shortcomings. An assumption that issues identified at one Trust are to be found generally across the NHS is at least questionable.
The impact on NHS management and patient safety
In her introduction to the report, Lady Justice Thirlwall asked that those who comment on the report respect the victims and their experience. I certainly intend no disrespect. Through my professional and on occasion private life, I believe I have acquired at least a sufficient degree of insight into traumatic bereavement to understand the effect, often lifelong, that it can have upon a victim. I also appreciate the deep wish of victims that no one else should experience a similar event. But I would suggest that the recommendation for the installation of CCTV cameras in cots in all neonatal units with a ring-fenced expenditure is going beyond a reasonable outcome for an investigation of the relevant facts. Prior to the convictions of Lucy Letby, the last recorded similar events resulted in the conviction of Beverley Allitt in 1993. It was acknowledged by those acting for the victims that the use of this CCTV would not avoid the risk of any similar event, but that it would make “the act of causing harm to babies considerably more difficult”.
NHS England after some prevarication were not prepared to support the suggested recommendation. Lady Justice Thirlwall described their position as being “disappointing and puzzling”. NHS England referred, amongst other issues, to “other priorities to improve neonatal services”. It is hard to imagine that there is any neonatal unit in the NHS that could not identify immediately further equipment that they would wish to purchase and which would have value in improving clinical care. The total number of monitors required to comply with the recommendations would be 3,500 which Lady Justice Thirlwall described as “minimal in the scheme of NHS expenditure”, which is a surprising justification. Expenditure in the NHS requires some form of risk benefit analysis and comparison made with other equipment which will not be purchased if (as in this case) money is spent on in-cot cameras.
The 2024 Inquiry by the House of Lords resulting in the report “Public Inquiries; enhancing public trust” suggested that they wasted massive amounts of time and public money by “reinventing the wheel”. A number of recommendations in the Thirlwall Report can be seen as essentially mirroring identified shortcomings or incidents as found in the report. It is also conspicuous that in speaking of, for example, protocols or steps, the implementation of the recommendation would require considerable managerial time and energy.
Predictably, the healthcare community has described the report as standard management bashing. HSJ (the journal for healthcare professionals) described the summary findings as “patronising, confusing and in some cases plain ignorant”. Lady Justice Thirlwall stated that there was “no difference between being a manager in the NHS and a senior manager or leader of a company listed on the FTSE 100.” I have significant experience of engaging with NHS managers through my professional practice. What always strikes me about them is the degree of pressure upon them and the nature of that pressure. Whilst managers of FTSE 100 companies may have to face an irate Board of Directors when the company is not in profit, they do not on a daily basis have to take decisions which have implications for patient care and safety. In my dealings with NHS managers, I notice how swiftly they move from meeting to meeting and from item to item on agendas at meetings.
In this context, the accumulation of recommendations through public inquiries does not assist in improving NHS management. Managers are already faced with a barrage of guidance, policies and protocols. The implementation of the Thirlwall recommendations would involve considerable management time and resource, including at Trusts which are accepted as operating to a high standard.
Towards a more joined-up approach to patient safety
There is a culture change in relation to public inquiries which I would advocate. In“Medical accidents: a Socratic Resolution?” Professor Gus Baker, Sam Irving and I argued that the response to medical accidents and adverse events was essentially a patchwork of processes, which was outmoded, resulting in a lack of clear overview. Public inquiries are part of this confused and inconsistent response to adverse clinical events. The various processes, to include discipline of professionals, inquiries, and litigation, are not merely inconsistent, but often come into conflict with each other. What is required is some form of a joined-up approach which could reasonably and simultaneously address all concerns arising out of the relevant event in a way which would better promote patient safety and address patients’ concerns. Examination of facts in public could, in appropriate cases, be part of the process. However, the establishing of facts would be a much less protracted and costly way of proceeding when the need for recommendations was removed.
