The Thirlwall Inquiry has concluded that some infants could have been spared death and injury at the hands of Lucy Letby if protective measures had been implemented sooner. The inquiry, established in 2023 following the former nurse's convictions for murder and attempted murder of babies at the Countess of Chester Hospital, also found that parents were "left in the dark" as the hospital carried out its own investigations.
Complete failure to protect babies
Releasing her final report on Tuesday, Lady Justice Thirlwall declared: "There was a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital. This was because no-one seems to have understood that safeguarding action is required when a member of staff is suspected of causing deliberate harm and does not require colleagues to be sure of guilt."
She added: "My report describes dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals of safeguarding."
Lady Justice Thirlwall continued: "How many lives could have been saved had the hospital acted differently? This is something we will never know for sure. It is clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier."
Hospital's response to concerns
The investigation did not scrutinise Letby's convictions or motives but instead concentrated on the behaviour of those employed at the Countess of Chester, including the board, managers, doctors and nurses from when Letby commenced her employment in 2012. Letby, 36, was transferred from the neonatal unit to administrative roles in July 2016 following consultants raising concerns about her to the hospital's executive team.
Hospital management chose to conduct several reviews into the rising mortality rates in 2015 and 2016, and failed to contact Cheshire Constabulary until May 2017, while Letby continued working on site until her arrest over a year later. The report determined that senior nurses never acknowledged that the consultants' concerns were, or could be, valid, and that there was an extended delay by senior management in contacting the police.
It concluded that successive internal and external reviews commissioned by hospital leadership after concerns were raised about Letby failed to examine whether deliberate harm was occurring or not.
Recommendations and next steps
A total of 14 recommendations have been outlined in the report, including installing baby monitors in all cots and incubators within neonatal units and CCTV cameras directed at insulin storage fridges. Lady Justice Thirlwall stated baby monitors would enable parents to watch their babies "remotely at any time" – adding that NHS England should "set out a roadmap" for how it could be implemented by March 31 next year.
She also stated digital devices should be utilised to "restrict access of insulin to authorised people", as well as logging access to insulin units. Another suggestion was that all managers should be subject to an "individual duty of candour to all patients and colleagues", and a code of conduct for senior managers should "set out, at the beginning, the uncontroversial duty of every manager to put patients first."
The chairwoman also determined that parents of Lucy Letby's victims were "kept in the dark" about suspicions held by the hospital. The report concluded that families of the babies remained unaware of concerns until the nurse was arrested and they were contacted by police in July 2018.
She said: "I would like to thank the parents of all the babies who died or were injured. Their evidence, generously given, was amongst the most thoughtful and moving any person will ever hear. Throughout a very difficult and prolonged process, the parents have conducted themselves with dignity and determination, with the aim that no other parents should have to experience such grief and heartache."
Letby, hailing from Hereford, who continues to assert her innocence, is serving 15 whole-life sentences for the murders of seven babies and attempted murders of seven others by various means between June 2015 and June 2016. She was twice refused permission to appeal against her convictions in 2024.
The Criminal Cases Review Commission, which probes potential miscarriages of justice, is currently examining evidence presented on her behalf by an international panel of medics who argue that poor medical care and natural causes were the reasons for the babies collapsing. A court order is in place preventing the disclosure of the identities of the surviving and deceased children involved in the case. Investigations by Cheshire Constabulary into potential charges of corporate manslaughter and gross negligence manslaughter are still underway. Inquests into the deaths of babies who Letby was found guilty of murdering are scheduled for May 2027.
