The government has set out immediate steps designed to improve patient safety and safeguarding, following the publication of the Thirlwall Inquiry.
Lady Justice Thirlwall’s final report into the Countess of Chester Hospital was published yesterday and found serious failures of governance, leadership and safeguarding, with opportunities missed to act on concerns and protect babies from harm.
In response, Health and Social Care Secretary, Yvette Cooper said safeguarding must be at the heart of the NHS and that the Government would act on the Inquiry’s recommendations to help prevent such failures happening again.
The recommendations include urgent work to develop plans for CCTV, including “cot cams”, in neonatal settings to improve safety and provide reassurance to parents and new guidance on the safe use and storage of insulin and strengthened guidance for Medical Examiners reviewing neonatal deaths.
Rollout of the national Bereavement Care Pathway for families experiencing neonatal loss will continue with all NHS trusts now signed up to implement it.
A single tracker will be created to monitor delivery of recommendations from major maternity and neonatal reviews and inquiries, helping ensure reforms are implemented and progress is transparent.
There are also plans to regulate NHS managers through a barring scheme for senior leaders who fail in their responsibilities.
Cooper said: "The safety and care for babies, the safeguarding of every patient, the respect for families – all these goes right to the heart of our NHS values.
"The Inquiry recognises that in many areas things have changed since these terrible events took place including welcome improvements at the Countess in services for women and children.
"However the inquiry is clear that new action is needed.
"I take these recommendations extremely seriously and the Government will of course consider the entire report and set out a full response.
"Safeguarding is everyone’s business, and safeguarding must be everyone’s priority. Concerns must be heard and acted upon. Staff who speak up must be protected and taken seriously, and I expect every leader, every board across the NHS, every professional and manager, every member of staff, to uphold their safeguarding responsibilities."
