Statement on the findings of the Thirlwall Inquiry
The Thirlwall Inquiry was set up to examine events at the Countess of Chester Hospital.
The findings of Thirlwall Inquiry into events at the Countess of Chester Hospital, published today, are profoundly distressing – especially for the families, the most important people in all of this.
Professor Mary Dixon-Woods, Director of THIS Institute at the University of Cambridge, provided expert evidence to theInquiry. She explained that cases involving extreme misconduct are exceptionally rare in the NHS, but when they do occur they tend to have repeated features.
Many of the organisational patterns described by the Inquiry are painfully familiar from earlier failures in healthcare. The risks do not necessarily present themselves clearly and cleanly in the early stages – perhaps taking the form of unease, discomfort, and unusual patterns, and perhaps being easy to explain in another way. Acting on these kinds of weak signals is often very challenging, requiring skill and judgement – but also sound systems that work in a coherent, coordinated way to support action.
The Inquiry report emphasises that when such concerns begin to emerge, it is critical that systems, process and behaviours are joined up, coherent, and make patient safety the priority. But that is not what happened at Countess of Chester. Uncomfortable evidence was discounted; governance processes failed; management was weak and biased; interpersonal conflict and interprofessional tension was rife; families were excluded; the procedures that were in place, including safeguarding, were not followed, and reputational and employment considerations interfered with an effective response.
Lady Thirlwall’s meticulous analysis and practical recommendations should support NHS organisations in developing the capability, confidence and authority to act when there are concerns. A particularly welcome recommendation is for a Suspicion of Deliberate Harm Protocol. This will help to address the problem that NHS systems have too often been designed around an assumption that challenges to patient safety arise primarily from unintentional error, without sufficient attention to the rarer but devastating possibility of transgressive behaviour.
The priority must now be sustained implementation of Lady Thirlwall’s recommendations. The families affected deserve nothing less.