A public inquiry has concluded that systemic failures at all levels of management and staffing at the Countess of Chester Hospital allowed former neonatal nurse Lucy Letby to murder seven babies and attempt to kill seven others between 2015 and 2016. The Thirlwall Inquiry, led by Lady Justice Kathryn Thirlwall, found that earlier intervention by hospital leadership and staff could have prevented some of the deaths and injuries, according to a report published on Tuesday.
Former hospital executives apologize for police delay
Three former senior managers at the Countess of Chester Hospital—former chief executive Tony Chambers, former medical director Ian Harvey, and former director of nursing Alison Kelly—testified before the inquiry that they regret a significant delay in alerting Cheshire Police to concerns about Letby’s conduct. Speaking on their behalf, counsel Kate Blackwell KC stated that the managers believed they needed to first conduct internal reviews to gather evidence before involving law enforcement. “This was a cause of a significant delay in contacting the police and for this, they are truly sorry,” Blackwell said. The managers acknowledged that guidance on when to involve police in hospital settings was overdue and expressed appreciation for the inquiry’s potential recommendations.
Concerns about Letby’s behavior were first raised in June 2016, but police were not formally notified until May 2017—nearly a year later.
Judge cites 'complete failure' to protect babies
In her report, Lady Justice Thirlwall did not review Letby’s criminal convictions but instead examined how institutional failures exposed babies to repeated harm and how hospital staff and management responded. She stated that errors were made by nurses, doctors, and managers, and that there was a ‘complete failure at all levels’ to invoke safeguarding procedures at any point. Thirlwall emphasized that some babies could have been saved if action had been taken sooner, asking, “How many lives could have been saved had the hospital acted differently?”
The inquiry heard from more than 130 witnesses and reviewed 400 statements over six months. Thirlwall also criticized the hospital’s treatment of parents, stating that they were ‘kept in the dark for years’ about concerns their children may have been deliberately harmed. She described this as ‘reprehensible’, noting that executives used the risk of upsetting parents as a justification for not contacting police.
Letby maintains innocence; legal challenges continue
Letby, 36, is serving 15 whole-life prison sentences after being convicted in 2023 and 2024 for the murders of seven infants and the attempted murders of seven others. She has consistently maintained her innocence, and her legal team, backed by an international panel of scientists, has submitted evidence to the Criminal Cases Review Commission (CCRC) in an effort to overturn her convictions. The CCRC is currently reviewing the case, with chair Dame Vera Baird stating she would consider the inquiry’s findings.
Inquiry recommends sweeping hospital safety reforms
The Thirlwall Inquiry issued 14 recommendations aimed at preventing future tragedies, including the installation of baby monitors in all cots and incubators in neonatal units and CCTV cameras focused on insulin storage fridges. Lady Justice Thirlwall stated that baby monitors would allow parents to observe their babies remotely at any time and urged NHS England to set a roadmap for implementation by March 31, 2025. She emphasized that the cost of these measures should be centrally managed and ring-fenced to ensure rapid deployment.
The inquiry’s report comes nearly two years after hearings concluded and follows multiple delays, including the postponement of inquests into the deaths of six babies Letby was convicted of murdering until May 2025.
Timeline of key events
- June 8, 2015: Baby identified as Child A is born six weeks premature and dies within 90 minutes of Letby’s night shift.
- June 8-11, 2015: Child A’s twin sister, Child B, is injected with air by Letby and survives after resuscitation.
- June 14, 2015: Child C, born seven weeks premature, dies after air is injected into his stomach by Letby.
- June 2016: Hospital staff raise concerns about Letby’s conduct.
- May 2017: Cheshire Police are formally notified of concerns.
- 2023-2024: Letby is convicted of seven murders and seven attempted murders; sentenced to 15 whole-life orders.
- September 2024: Thirlwall Inquiry report published, outlining systemic failures and recommending reforms.