The record

Reviews

Each entry is one inquiry, investigation, policy review or national strategy. Open a review for the findings, the paraphrased recommendations, and the other reviews that share its themes.

SearchTypeSettingThemeStatus

FromToClear

8 reviews

2026Statutory inquiryPublished

Thirlwall Inquiry

Lady Justice Thirlwall

Statutory inquiry into events on the neonatal unit at the Countess of Chester Hospital between 2015 and 2018, after the convictions of Lucy Letby. Hearings ran from September 2024 to March 2025. The report was published on 15 September 2026 and made 17 recommendations. It examined the unit, the executives, the regulators, and why concerns raised by clinicians were not acted on. It also reviewed whether earlier inquiry recommendations had been implemented.

Accountability of managers Bereavement care Candour+12

Children

England

18 recommendations in this hub

2024Independent reviewPublished

Cass review

Dr Hilary Cass

Independent review of NHS gender identity services for children and young people. It found a weak evidence base, a service that had not kept up with a rapid rise in referrals, and a need for ordinary, holistic children's healthcare around gender-related distress.

Children and safeguarding Data and early warning Inequalities+4

Children

England

3 recommendations in this hub

2018Statutory inquiryPublished

Hyponatraemia Inquiry

Mr Justice O'Hara

Statutory inquiry into the deaths of children in Northern Ireland hospitals, including deaths associated with hyponatraemia and fluid management. It found failures of care, candour and how the system treated families afterwards.

Candour Children and safeguarding Culture and conduct+2

Children

Northern Ireland

2 recommendations in this hub

2011Policy reviewPublished

Munro review

Professor Eileen Munro

Review of child protection after a decade of procedural reform. It argued that the system had become too focused on compliance and not enough on whether children were safer.

Children and safeguarding Data and early warning Regulation and oversight+2

Children

England

2 recommendations in this hub

2003Statutory inquiryPublished

Victoria Climbié

Lord Laming

Public inquiry into the murder of Victoria Climbié and the failure of health, police and social services to protect her. Information sat in separate organisations and was not acted on.

Children and safeguarding Data and early warning Integration and neighbourhood care+2

Children

England

2 recommendations in this hub

2001Independent reviewPublished

Alder Hey (Redfern)

Michael Redfern KC

Inquiry into the removal, retention and disposal of human tissue at Alder Hey and related practice elsewhere. Families had not agreed to what happened to their children's organs.

Bereavement care Candour Children and safeguarding+4

Children

England

2 recommendations in this hub

2001Statutory inquiryPublished

Bristol Royal Infirmary

Professor Sir Ian Kennedy

Public inquiry into the care of children undergoing heart surgery in Bristol between 1984 and 1995. It found a service with poor outcomes that families and some clinicians could not get the organisation to face.

Candour Children and safeguarding Culture and conduct+4

Children

England

3 recommendations in this hub

1994Independent reviewPublished

Clothier (Allitt)

Sir Cecil Clothier

Independent inquiry, chaired by Sir Cecil Clothier and published in February 1994, into the murders and attacks committed by enrolled nurse Beverly Allitt on a children's ward at Grantham and Kesteven General Hospital. The report was published in print by HMSO. It made recommendations on staff references, occupational health screening, paediatric pathology and the reporting of unexpected events.

Children and safeguarding Data and early warning Leadership and boards+4

Children

England

3 recommendations in this hub