A personal view by David Czarnetzki
On 15th September 2026, Lady Justice Thirlwall published her long-awaited report into events surrounding the Countess of Chester NHS Trust outlining the findings at a press conference that morning. The report runs to 800 pages in three volumes. It did not touch on the guilt or innocence of Nurse Lucy Letby but it did make 17 recommendations. Recommendation 16 related to the Parliamentary and Health Service Ombudsman and is reproduced below:
Parliamentary and Health Service Ombudsman
The functions of the National Guardian’s Office should be taken over by the Parliamentary and Health Service Ombudsman in England. The Ombudsman’s powers must be increased to include:
- investigating complaints that whistleblowing in the NHS has not been dealt with adequately
- assisting whistleblowers by referring their concerns to the relevant NHS bodies and overseeing the response.
Sir Rob Behrens gave evidence to the inquiry by way of a written statement dated 13th March 2024. Here, Sir Rob was keen to point out the number of complaints concerning the NHS received by the Ombudsman each year from 2011 to 2023.
What wasn’t disclosed was the number of complaints upheld by the organisation. These have previously been revealed on PHSO The True Story and show a steady decline under Behrens stewardship, which began in April 2017.
In his written evidence Behrens confirms that, “We have received no complaints about the care of babies at the COCH’s neonatal unit between June 2015 and June 2016 (inclusive).”
He also gave oral evidence on 10th December 2024 Q & A.
Currently, the Ombudsman cannot take issues raised by whistleblowers on board and the recommendation for this to be included in the Ombudsman’s remit, together with the function of the National Guardians Office, is a rare step.
The Health Secretary, Yvette Cooper, made a statement in the House of Commons in the afternoon.
In her statement, the Health Secretary was keen to agree with several of the Inquiry’s recommendations. However, she was silent on recommendation 16. The report has, of course just been published and will need detailed reading. However, bearing in mind the attitude of Government in recent years, irrespective of the party in power, I cannot help but wonder whether legislation to provide Ombudsman reform will ever come forward.
So – the questions are:
- Will PHSO take over the work of the National Guardians Office?
2. Would it operate on a more regional basis or be more of the same paper-shifting out of London & Manchester?
In his evidence, Sir Rob laments the lack of power vested in the Ombudsman, though no Ombudsman has ever requested powers of compliance. It is not difficult to see why they are restricted, bearing in mind how a former Prime Minister quashed the hopes of the WASPI women at the despatch box in December 2025.
It is questionable whether taking on the work of the National Guardians office would actually improve access to justice for whistleblowers, given the difficulty PHSO are already having managing their workload and their appalingly low uphold rate.
Just shifting a few deck chairs around on an already sinking ship.
Thank-you once again.
Unlike whistleblowers, courageously seeking to report in-service failings, mere complainants have no status, and very little hope that the evidence they present will be respected.
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Listening to Ms Cooper in the video clip shows it’s not even a masterclass in redirection, it’s so obvious nowadays to most people, who have not lost the innate quality of critical thinking, to come across as a complete ‘nothing to see here’ conclusion by the legislature.
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Thanks David and Della I hadnt heard of this. If it were to go ahead, I cant see there being a rapid response to an immediate concern. Cheers Margaret
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You are so right. The concerns of whistleblowers need to be addressed immediately they are raised. PHSO does not seem to have capacity to deal with anything promptly. Their website has been advising of the delays in investigations.
There is also the question of legislation. To even comply with this one recommendation will need parliamentary time to change the law.
In addition, the Ethics and Integrity Commission are currently conducting a review into the public sector ombudsman system. PHSO the Facts has submitted evidence but none has yet been published.
To summarise, we have Lady Justice Thirlwall making a recommendation, the Ethics and Integrity Commission having a look and, of course, our parliamentarians at PACAC who have been calling for Ombudsman reform for years and who yet have to report on their PHSO inquiry opened in January 2026.
I have no expectation other than this will either be kicked into the long grass or any future reform will be unlikely to aid in the public search for openness and transparency.
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Lucy Letby was convicted of murdering seven babies and attempting to murder seven others, receiving 15 whole-life prison sentences, but a growing debate questions whether she was treated as a scapegoat for systemic NHS failures
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As expected this aspect was not considered by Thirwall.
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Evil
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