The publication of the report marks the conclusion of the Thirlwall Inquiry, which investigated events at the Countess of Chester Hospital between 2015 and 2018. Among many things, the report examines how concerns were identified and escalated, the decisions made by clinicians and senior managers, the effectiveness of safeguarding processes and the role of regulators and other oversight bodies.

In doing so, the inquiry demonstrates how public inquiries are increasingly being used not only to understand what happened, but also to identify lessons capable of driving future improvement and reform.

Public inquiries have become an increasingly prominent feature of the legal, political and regulatory landscape. From healthcare to local government, housing and education, they are frequently established following serious incidents that raise concerns about organisational failings, public confidence or wider systemic issues.

The Thirlwall Inquiry also illustrates the breadth of issues that can fall within an inquiry's scope, extending beyond the events themselves to consider leadership, governance, safeguarding and organisational decision-making.

What do public inquiries examine?  

Public inquiries are established to investigate matters of significant public concern, understand what happened and identify lessons for the future. They do not determine criminal guilt or civil liability.

Their scope, however, often extends far beyond the immediate events under investigation.

The Thirlwall Inquiry, for example, examined not only the offences committed against babies on the neonatal unit at the Countess of Chester Hospital, but also the effectiveness of safeguarding arrangements, leadership responses, governance structures, relationships between clinicians and senior managers, and the role of regulators and oversight bodies.

The inquiry concluded concerns raised by consultant paediatricians were not acted upon with sufficient urgency and that opportunities to escalate concerns to safeguarding bodies and the police were missed. It also found patient safety considerations became subordinated to other priorities, contributing to delays in intervention.

What public inquiries often reveal  

While every inquiry is different, certain themes recur across many investigations.

One of the most striking features of public inquiries is the extent to which decisions are revisited years after they were taken. Board papers, meeting minutes, risk registers, internal reports and email correspondence often become key evidence in understanding what information was available at the time and why particular actions were taken.

For organisations, this highlights the importance of effective governance and good record keeping. For individuals, it serves as a reminder decisions taken in good faith and under significant operational pressures may later be examined in considerable detail through documentary evidence and witness testimony.

Public inquiries also explore how concerns were identified and addressed. The Thirlwall Inquiry, for example, examined whether concerns expressed by clinicians were appropriately recognised, escalated and investigated. The report concluded there was a widespread failure to appreciate safeguarding action may be required on the basis of concern or suspicion, rather than certainty or proof.

These are not issues unique to healthcare. Across many sectors, inquiries examine whether concerns were taken seriously, whether reporting mechanisms functioned effectively and whether organisations responded appropriately when risks first emerged.

The practical challenges of a public inquiry  

For both organisations and individuals, involvement in a public inquiry can be a significant undertaking. 

The process often involves extensive engagement with inquiry teams, detailed witness statements, large-scale document review exercises and, in some cases, oral evidence at public hearings. Events that occurred many years earlier may be revisited through historical records, correspondence and witness recollections. 

For organisations, this can create operational, regulatory and reputational challenges alongside the practical demands of responding to requests for information and evidence. For individuals, participation may involve explaining decisions made many years earlier and in circumstances that are only fully understood with the benefit of hindsight. 

Whether involved as an organisation, a witness or a participant with a significant interest in the issues under investigation, effective preparation can help ensure evidence is presented clearly, accurately and in its proper context. 

From findings to implementation  

One of the more notable themes emerging from the Thirlwall Inquiry is its focus on what happens after an inquiry concludes. The report highlights concerns recommendations arising from previous NHS inquiries have not always been implemented effectively or consistently, despite often being accepted in principle.

The inquiry includes a dedicated review of how recommendations from earlier NHS inquiries have been implemented and concludes a lack of follow-through, unclear ownership and insufficient oversight have frequently limited their impact. It therefore recommends stronger mechanisms for monitoring implementation and ensuring lessons lead to meaningful and lasting change.

For organisations, this is an important reminder the publication of an inquiry report is rarely the end of the process. Increasingly, stakeholders, regulators and the public expect organisations not only to consider inquiry findings but also to demonstrate how lessons have been implemented and embedded into day-to-day practice. 

In many respects, the lasting impact of a public inquiry is determined not by the publication of its report, but by the actions taken in response to it. 

The wider implications of Thirlwall  

The recommendations arising from the Thirlwall Inquiry are wide-ranging and are likely to shape future discussions around safeguarding, whistleblowing, accountability and the responsibilities of senior leaders. The report also makes recommendations on issues including the implementation of inquiry recommendations, stronger accountability mechanisms for NHS managers, CCTV monitoring in neonatal units and improved systems for identifying and responding to patient safety concerns.

More broadly, the report highlights the continuing importance of public inquiries as a means of understanding what went wrong, identifying lessons and driving improvement. With a number of significant public inquiries currently underway across a range of sectors, organisations and individuals alike may wish to consider not only the lessons arising from inquiry reports, but also how their own decisions, systems and responses would withstand scrutiny if examined in a public inquiry setting.