The findings of the public inquiry into how Lucy Letby was able to repeatedly murder and harm infants on a hospital neonatal ward are due to be released later today. The Thirlwall Inquiry, established in 2023, will publish its report on Tuesday, September 15, following the former nurse's sentencing to 15 whole-life terms for the murder and attempted murder of babies at the Countess of Chester Hospital.
Inquiry scope and focus
Senior judge Lady Justice Thirlwall's findings will not scrutinise Letby's convictions or underlying motivations. Instead, the inquiry concentrates on the behaviour of staff at the Countess of Chester, including the board, management, doctors, and nursing staff from the point Letby started her employment in 2012.
Letby, 36, was transferred away from the neonatal ward to clerical responsibilities in July 2016 after consultants raised concerns about her to the hospital's senior leadership. Hospital management chose to conduct several reviews into the elevated death rate in 2015 and 2016, and did not contact Cheshire Constabulary to launch an investigation until May 2017, while Letby continued working on the premises until her detention over a year afterwards.
Culture and governance under scrutiny
The inquiry scrutinised whether concerns ought to have been flagged earlier and whether police and other external agencies should have been alerted more promptly. It examined the response to concerns raised about Letby, and whether the culture, management and governance structures of the hospital trust, and the broader NHS, played a role in the failure to safeguard the infants from Letby.
The inquiry additionally heard evidence regarding whether the accountability of senior managers ought to be reinforced. Sir Robert Francis, who presided over the inquiry into chronic care failings at Mid Staffordshire NHS Foundation Trust, informed Lady Justice Thirlwall that no regulator existed "with teeth" to impose sanctions on poorly performing non-clinical directors.
Letby's convictions and ongoing review
Letby, from Hereford, who maintains her innocence, is serving 15 whole-life terms for the murders of seven babies and attempted murders of seven others by various means between June 2015 and June 2016. She was twice denied permission to appeal against her convictions in 2024.
The Criminal Cases Review Commission (CCRC), which investigates potential miscarriages of justice, is currently examining evidence submitted on her behalf by an international panel of medical professionals who contend that inadequate medical care and natural causes were responsible for the infants' collapses. A number of doctors, scientists and statisticians have publicly questioned the manner in which evidence was presented to jurors during her trial.
Legal challenges and next steps
Letby's lawyers have insisted her CCRC case has not been undermined after two experts quit her defence team on Monday, saying some of its arguments have "unresolvable problems". Engineering specialist Helen Shannon and bioengineering professor Geoff Chase stepped down from the team while the CCRC reviews its conclusions.
Last year, Lady Justice Thirlwall dismissed separate requests from Letby and the Countess of Chester's former senior management to suspend her inquiry while awaiting the outcome of Letby's appeal to overturn her convictions. Solicitors acting for Letby contacted her expressing concerns that the final report would "not only be redundant but likely unreliable", and should the convictions be quashed, would be "based on the wrong premise". Legal representatives for the management team during 2015 and 2016 suggested there was a "real possibility" the convictions would be overturned.
However, legal teams representing the families of Letby's victims described it as yet another "cynical attempt" by the former nurse to control the narrative, adding that the executives wanted to avoid criticism. They stated there was "nothing remarkable or new" about the evidence put forward by the international panel of medical professionals.
A court order prevents reporting of the identities of the surviving and deceased children connected to the case. Investigations by Cheshire Constabulary into potential offences of corporate manslaughter and gross negligence manslaughter continue. Inquests into the deaths of the babies whom Letby was convicted of murdering are scheduled to be held in May 2027.
