Report for the Thirlwall Inquiry: Analysis of questionnaires from 120 NHS trusts

This report was commissioned by the Thirlwall Inquiry in January 2024.  The Inquiry was set up “to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital”.

The report compiles and presents the analysis of responses to a questionnaire that was sent by the Inquiry to all 120 NHS trusts with neonatal units in England (except for the Countess of Chester and one other trust which was engaged with an inquiry process) for completion in November 2023.  

The purpose of the report was to identify and summarise key issues and themes from the questionnaire responses. With the evidence and submissions phase of the Inquiry now closed, the report has been made publicly available by the Thirlwall Inquiry. We publish the report here in the form submitted to the Inquiry as of April 2024. The report download is available below, and what follows is a short overview of findings about key topics.

Read the report

About the survey and our report

The report aims to provide an overview of the organisation of neonatal care, and draws on previous work by the Nuffield Trust along with wider research and guidance relevant to neonatal care.  Trusts were asked by the Inquiry to provide separate responses from medical and non-medical leaders, although in some cases single or shared responses were provided.

The survey addressed the following topics:

• Governance and accountability
• Trust policies
• Staffing
• Culture
• Working relationships
• Reporting and managing concerns and complaints
• Reviewing evidence after a death
• Safety nets, including parental involvement in care, CCTV, medication management and use of data
• Support for bereavement
• Learning and making improvements
• Regulation of senior managers

Additional documents were provided in support of responses by some organisations.  In the analysis we used examples from responses to illustrate common themes identified, as well as less common responses, and examples where trusts identified good practice or challenges.  We have not been able to follow-up with trusts to validate responses, which were not anonymised.  Please see the introduction of the report for further detail of our approach.

Findings about key topics

Governance and accountability

Trusts noted that they, or their Board, are accountable to a range of organisations for different things, for example in relation to performance, finances and quality.

Trust policies

About half of the respondents (61 trusts) reported that they had reviewed their policies during 2023. For most of those (39 trusts), their reviews of policies were triggered by the Letby case. But another 10 trusts reported reviews being triggered by changes in national guidance on safeguarding and/or the introduction of the new national Patient Safety Incident Response Framework.

Staffing

Most trusts reported challenges with meeting staffing requirements, relating to the number, skill mix and qualifications of staff. For example, 99 trusts reported that they had nursing vacancies, and 68 trusts reported that they did not meet staffing standards for nurses.  Trusts were using a range of strategies to address staffing gaps, including training existing staff, developing different roles, and international recruitment.  On a day to day basis trusts described how they monitored staffing levels relative to how busy they were and the needs of babies, and brought in additional staff if needed, or in some cases changed admission criteria to maintain safe staffing levels.

Culture

Responses to the questionnaire indicated that culture across trusts and neonatal units is complex, can vary and was dependent on local and national context. While some trusts described particular challenges (either in the neonatal unit or trust as a whole), many described features of their trust which they considered demonstrated a good culture. Some also reflected on changes and improvements over time, the impact of previous incidents and reviews, and organisational priorities to improve culture, noting that culture was not static and developing a good culture requires continuous attention.

Working relationships

Describing working relationships within neonatal units across the NHS as a whole is complex, and dependent on the particular context.  Responses to the questionnaire indicate several features which were considered to be important to enable individuals and teams to work together. This included multi-disciplinary team working and leadership, mechanisms to support communication and visibility (such as listening events, huddles and walkarounds) and forums for raising or discussing issues (such as Committees). Some trusts referred to challenges with working relationships which included differences in opinion, the impact of staffing or service pressures such as industrial action and hierarchies.

Reporting and managing concerns and complaints

There was broad consistency in how respondents described their processes for reporting and investigating concerns/complaints. Multiple teams were described as responsible for investigating concerns/complaints based on the issue.

Respondents described a range of factors inhibiting staff from raising concerns (for example lack of a reporting culture, and low staffing levels and resourcing leaving little time to raise and investigate concerns/complaints) as well as enabling factors (such as continuous encouragement for reporting, training programmes and leadership being visible and building in mechanisms to listen).

Reviewing evidence after a death

There were multiple routes described for reviewing evidence after a death including local governance processes and external review and reporting processes. Many respondents reported how such processes aim to support local and broader learning, provide explanations to families, maintain accountability and transparency, oversight and assurance, and benchmark against national and regional standards. Factors influencing learning included services having an open culture, thoroughness of the investigation, triangulation and communication across services and processes, and capacity to embed learning into practice.

What safety nets exist

Parental involvement: There are established approaches and initiatives in neonatal care for involving parents. Most trusts cited established processes for parental involvement in ward rounds, the sharing of discharge summaries, engagement in care activities and ensuring 24-hour access to the unit.

Data collection and use of data: There are established national reporting and monitoring requirements relating to neonatal care, and trusts used data for operational management and monitoring staffing, reviewing quality of care and quality improvement, for national and local benchmarking and audit, and financial and contracting requirements.  Monitoring and reporting is impacted by wider trust infrastructure, particularly use of electronic health records.

Presence of CCTV: While most respondents reported the presence of CCTV within or outside services, this was usually located at entrances and exits (and some communal areas) for the purpose of ensuring the security and safety of staff and patients. No respondents reported CCTV to be located within clinical areas with the purpose of monitoring babies and few reported its presence in medication storage areas.

Management, storage and administration of medication: The management, storage and administration of medication within maternity and neonatal services was determined by national guidance and local trust policies. Differences were evident across trusts in relation to the digital capabilities of storage facilities (such as automated electronic storage units), the availability of electronic systems for records of access and administration, and the frequency with which regular audits were carried out for the safe and secure storage and administration of medication.

Support for bereavement

A wide range of bereavement support services were described as available with common services including access to a bereavement midwife, Perinatal Mortality Review Tool review with consultants, referrals to specialist bereavement counselling services where needed, and referral to a perinatal mental health midwife or a clinic for future pregnancies dedicated to parents who have experienced baby loss.

Learning and making improvements

Some trusts provided specific reflections on lessons learned regarding neonatal and perinatal services. These included the importance of data (and ensuring it is visible at board level), processes and cultures which enable people to raise concerns, integrated working between neonatal and maternity services, and relationships between professionals.

Regulation of senior managers

Respondents expressed a range of views regarding regulating senior managers. Some expressed a clear position either in support of regulation or against it, some expressed a more qualified position and others were neutral or undecided on the topic.

Key themes which were identified by both medical and operational respondents included the purpose of regulation (for example, to support professional development and consistency of manager roles), the interrelatedness and effectiveness of existing processes (such as the fit and proper persons test), the appropriateness of the solution as a way to improve patient safety, and providing consistency with other regulated professions.

Overarching themes

For almost all the areas covered in the questionnaire there were existing regulations, mechanisms or guidance in place in the NHS.  Within neonatal services there were additional reporting routes and requirements to take into account over and above those which apply across the NHS as a whole. In a small number of areas (for example use of CCTV) we found limited guidance.

The infrastructure within trusts affected the processes they have in place to manage safety and risks. For example, there was variation between trusts in the availability of electronic systems to support access to medical records, medicines management and storage facilities, the maturity of systems for data collection, reporting and triangulating information, and ease of access to the ward for parents.

However, policies, structures and processes on their own are not sufficient to ensure services are safe and effective.  A wide body of research indicates that culture and leadership are critical, and a positive culture is needed for systems and processes to achieve their aims. Where there is variation in how trusts manage issues, this will reflect a combination of the circumstances of the organisation and the leadership approach to addressing issues.

Some organisational circumstances are unique, but there are many factors affecting the whole NHS, or neonatal care specifically, for example resource and workforce pressures. Culture and leadership at an organisational level are also impacted by national leadership and management of the NHS.  In some cases the quantity of guidance, reporting requirements, number of external regulators, and the frequency with which these change, leads to a risk that responding to external scrutiny takes precedence over learning and action within the organisation.