James Arrowsmith, Partner in social care at UK and Ireland law firm Browne Jacobson, which advised NHS England during the inquiry, provides his comments on what the report’s findings mean for local authorities and other social care organisations.
The Thirwall Inquiry final report was published this week, delivering one of the most significant recent assessments on NHS patient safety – but with implications too for social care.
The statutory public inquiry was established to examine the circumstances in which Lucy Letby, a neonatal nurse at the Countess of Chester Hospital, was able to murder seven babies and attempt to murder six others between June 2015 and June 2016.
The inquiry’s findings deserve careful and honest reflection by every organisation and professional involved in safeguarding, whatever their sector. From our experience working across public services, the specific challenges it identifies – while thankfully rarely resulting in consequences of this magnitude – are not uncommon. They are challenges that many organisations and partnerships encounter, and which require ongoing vigilance, openness, and a genuine commitment to learning.
What emerges clearly from the Inquiry is that an emphasis on process, compliance, and internal governance – at the expense of a clear focus on the outcome of keeping children safe – can create dangerous blind spots, even within organisations and systems that believe they are functioning well.
“The inquiry identifies how concerns were characterised as matters of employment and discipline rather than safeguarding; how the absence of evidence was treated as a reason for inaction, when the guidance is clear that genuine concern is sufficient to require a response; and how the critical multi-agency architecture designed to provide independent oversight was never engaged, because internal processes did not activate it.
The answers do not lie with individual organisations in isolation. The failings identified point to the importance of multi-agency working as a genuine safeguard in itself. ‘Working Together to Safeguard Children’ is clear that no single organisation can hold the complete picture, and that effective collaboration – including mutual challenge and constructive scrutiny between partners – is essential to delivering good outcomes for children.
Where those relationships are strong, and where partners feel able to ask difficult questions of one another, the system is more resilient. Where partners operate in silos, or where challenge is unwelcome, the gaps can remain invisible until it is too late.
The inquiry also highlights a structural challenge that deserves particular attention: that process compliance and outcome achievement are not the same thing. Bodies can fulfil their procedural obligations – conducting reviews, attending panels, filing notifications – and still fall short of the outcome those processes were designed to deliver.
That the local child death overview panel (CDOP) scrutinised deaths within its geographical footprint meant it complied with minimum requirements. However, with a neonatal unit attracting families from outside the area, this left a blind spot to deaths occurring on its doorstep. With a view to achieving the outcome of child safeguarding the CDOP could have chosen to examine these deaths also. Safeguarding requires active, curious, outcome-focused engagement.
There is much in this inquiry that every safeguarding partnership should reflect on carefully. We would encourage all safeguarding partners – local authorities, integrated care boards, police, NHS trusts, and the wider range of organisations with safeguarding responsibilities – to engage seriously and collectively with the Inquiry’s findings: not simply to audit their own processes, but to ask honestly whether their culture, their relationships, and their approach to challenge and scrutiny are truly focused on the right outcome. The question is not only ‘are we complying?’ but ‘are children safer because of what we do?
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