Key findings from Lucy Letby Thirlwall Inquiry
Inquiry finds repeated missed opportunities to protect babies at Countess of Chester
Constantvpn.com – The public inquiry examining how Lucy Letby was able to harm babies on the neonatal unit at the Countess of Chester Hospital has concluded that there was a “complete failure” to safeguard infants.
Lady Justice Thirlwall’s report follows six months of hearings, more than 130 witnesses and consideration of 400 written statements. Published at Liverpool Town Hall, the findings span more than 1,100 pages across three volumes.
The inquiry was established in September 2024 after Letby was convicted of murdering seven babies and attempting to murder seven others. One of the attempted murder victims was targeted twice. Letby, now 36, worked as a neonatal nurse at the hospital.
Early deaths were not treated as a warning pattern
A central finding was that a series of deaths in 2015 should have prompted a much stronger response. Babies A, C and D died during June that year, but their deaths were not recognised as a cluster, despite matching the unit’s usual annual number of deaths and occurring within roughly two weeks.
When baby E died unexpectedly in August 2015, the case was considered at a serious incident panel attended by the medical director and director of nursing. However, the review was handled as a procedural exercise rather than a meaningful examination of what had happened.
“What is surprising is that no connection was made by any of the people involved to the earlier deaths,” Thirlwall noted.
By August 2015, four deaths had occurred on the unit, the highest total since 2008. The figure would double by the end of that year. The inquiry found that the rising number of deaths was not addressed with the urgency needed to identify and remove risks to babies.
Insulin result should have triggered safeguarding action
The report identified the treatment of baby F as an especially significant missed opportunity. It found that safeguarding measures should have followed if Dr ZA had not dismissed an insulin test result in August 2015.
Lady Justice Thirlwall concluded that action at that stage would have prevented attacks on babies G, H, J, K, L, M and N, as well as the deaths of babies I, O and P.
The report also said that removing Letby from the ward by October 2015, after baby I’s death, would have stopped the deaths of babies O and P and prevented attacks on babies J, K, L, M and N.
Other critical moments were highlighted. In February 2016, Dr Ravi Jayaram should have reported what he witnessed in relation to baby K. In May 2016, safeguarding concerns were not raised at a meeting with hospital executives. The inquiry found that had the issue been raised then, babies O and P would not have died.
Thirlwall said it would not be possible to establish with certainty the precise number of lives that might have been saved. Even so, the report’s conclusion was unequivocal: the neonatal unit did not provide the protection vulnerable babies required.
Management and governance criticised
The inquiry described the hospital’s management and governance as dysfunctional. It found that senior leaders repeatedly failed in their duty of candour to parents, investigators and regulators.
“If all the babies whom [Letby] was convicted of murdering were removed from the annual number of deaths in the neonatal unit, the mortality figures would have been three in 2015 and three in 2016 - broadly consistent with previous years,” she wrote.
The report added that there had been one death on the unit since July 2016, in September 2019. This comparison underlined the inquiry’s view that the unusual mortality figures during the relevant period demanded closer scrutiny.
Thirlwall characterised the conduct of hospital leaders as “high-handed, against all safeguarding principles, and foolhardy.” Medical director Ian Harvey was found to have sought to shape the narrative and present the case in the way he understood it. The report said he ensured documents supporting his position were available, including by drafting material himself when necessary.
Director of nursing Alison Kelly, who was also head of safeguarding, knew action was required when there was suspicion that a baby had been harmed and that others could face risk, the inquiry found. Yet she did not act.
Chief executive Tony Chambers was criticised for what the report described as a dictatorial approach to consultants. Presentations by executives to the trust board were characterised as an “exercise in spin.” The inquiry found that he contributed to an unnecessary delay in approaching the police and that his intention was to delay or obstruct the investigation, succeeding for almost a year.
Concerns were not handled effectively
The report was also critical of numerous internal and external reviews commissioned by hospital leadership after concerns emerged about Letby. These processes did not provide the decisive response needed to protect babies or properly confront the concerns raised by clinicians.
Karen Rees, director of nursing for urgent care, was found to have “lost all judgement” and to have adopted a hostile approach. The inquiry also concluded that the judgement of neonatal unit manager Eirian Powell was influenced by her belief that Letby was a very good nurse.
The findings extend beyond individual decisions. Thirlwall said broader failings within the NHS contributed to what happened, including a tendency for management to focus on avoiding blame rather than responding openly and effectively to serious clinical concerns.
For families whose babies died or were harmed, the report sets out how warning signs accumulated without producing adequate safeguarding action. Its account is not only of isolated mistakes, but of repeated failures in escalation, leadership, scrutiny and transparency at moments when intervention could have protected children.
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