Context
The opening of the Thirlwall Inquiry in London on 10 September 2024. Lady Justice Thirlwall set out the Inquiry’s terms of reference and scope. Counsel to the Inquiry delivered a long opening statement addressing the matters the Inquiry would investigate over the following eighteen months.
The opening is important for three reasons. First, it delineates what the Inquiry is doing and, as importantly, what it is not doing — the Inquiry is not re-trying the criminal case. Second, it establishes the evidential base the Inquiry will consider: witness statements from consultants, executives, regulators and external reviewers. Third, it frames how the Inquiry’s eventual report will be read against the concurrent CCRC review.
What the Inquiry will examine
- How consultants escalated concerns between 2015 and 2016 and how those escalations were handled.
- The 2016 RCPCH Invited Service Review, its terms of reference, and how its findings were represented.
- The eight-month delay between the September 2016 consultants’ letter and the May 2017 police referral.
- The conduct of Trust executive and non-executive directors; the role of HR; the grievance sequence brought against consultants.
- The role of external regulators: CQC, NHS England, and the professional colleges.
- Wider NHS governance lessons for the handling of whistleblower concerns on patient-safety matters.
What it will not examine
Lady Justice Thirlwall was explicit that the Inquiry would not itself re-examine the medical evidence on which the criminal convictions rest. The criminal convictions, she said, are a matter for the appellate courts and the Criminal Cases Review Commission. The Inquiry proceeds on the basis of the verdicts as they stand. This is a legally correct position — a statutory public inquiry does not have criminal-appellate jurisdiction — but it sets up an important boundary: Inquiry findings about institutional failure will necessarily co-exist with, rather than displace, whatever the CCRC ultimately concludes.
Read alongside
Consultants’ letter (Sep 2016), RCPCH 2016 review report, Our analysis of the RCPCH review.