Key findings from Lucy Letby Thirlwall Inquiry
Inquiry finds repeated safeguarding failures at Countess of Chester neonatal unit
Ninoda.com – The public inquiry into the crimes of former neonatal nurse Lucy Letby has concluded that some deaths and near-fatal attacks on babies may have been avoided if safeguarding procedures had been properly followed at the Countess of Chester Hospital.
Lady Justice Thirlwall, who chaired the inquiry, said there had been a “complete failure to protect babies on the neonatal unit”. Letby, now 36, was convicted of murdering seven babies and attempting to murder seven others; one child was targeted twice.
She received 14 whole-life prison terms in 2023. A further whole-life sentence was imposed in 2024 after a retrial resulted in a conviction for an attempted murder charge on which the original jury had not reached a verdict.
“It will never be possible to know with certainty how many lives could have been saved,” Lady Justice Thirlwall said.
Unusual death pattern was not acted upon
The inquiry examined a series of warning signs that emerged during 2015 and 2016. Three babies — identified as babies A, C and D — died in June 2015. Although that number matched the neonatal unit’s usual annual death total, the deaths occurred within a two-week period and were not recognised as a concerning cluster.
When baby E died in August 2015, the death was unexpected and was considered at a serious-incident panel attended by the hospital’s medical director and director of nursing. The review, however, was treated as a procedural exercise rather than an opportunity to examine whether there was a wider pattern.
“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 babies had died on the unit, the highest annual number since 2008. That figure would later double before the end of the year. Thirlwall found that, without the deaths for which Letby was convicted, neonatal mortality would have been three in 2015 and three in 2016 — figures broadly in line with earlier years. Since July 2016, the unit has recorded one death, in September 2019.
Insulin result identified as a key missed opportunity
A significant missed warning came in August 2015, when baby F had an insulin test result. The inquiry found that safeguarding action should have followed if Dr ZA had not dismissed that result. Such intervention could have changed the course of later events, including by removing Letby from duties on the ward.
The report concluded that safeguarding action at that point could have prevented attacks on babies G, H, J, K, L, M and N, as well as the deaths of babies I, O and P. If action had been taken by October 2015, after baby I’s death, the deaths of babies O and P could have been avoided, together with attacks on babies J, K, L, M and N.
Other opportunities were also identified. In February 2016, Dr Ravi Jayaram should have reported what he had seen in relation to baby K. At a meeting with hospital executives in May 2016, safeguarding concerns were not raised. Thirlwall found that raising them then could have prevented the deaths of babies O and P.
Criticism of leadership, governance and openness
The inquiry described the hospital’s management and governance arrangements as dysfunctional. It found that senior figures repeatedly failed in their duty of candour towards parents, investigators and regulators.
Thirlwall described that conduct as “high-handed, against all safeguarding principles, and foolhardy.”
Medical director Ian Harvey was found to have sought to “control the narrative” and to have presented matters through his own interpretation. The inquiry said he ensured that material supporting his position was shown, including by preparing documents himself where necessary.
Alison Kelly, the director of nursing and head of safeguarding, understood that she had a responsibility to act where a baby might have been harmed and other children could be at risk, but did not do so. Unit manager Eirian Powell’s judgement was found to have been influenced by her belief that Letby was a very good nurse.
The inquiry was also sharply critical of chief executive Tony Chambers. It found that his approach to consultants was dictatorial and that presentations made to the hospital board by executives amounted to an “exercise in spin”. His conduct contributed to delay before police were contacted.
Thirlwall found that Chambers intended to stall or obstruct the police investigation and was successful in delaying it for almost a year. The report also criticised numerous internal and external reviews commissioned by hospital leaders after concerns about Letby had been raised.
Karen Rees, director of nursing for urgent care, was found to have “lost all judgement” and to have taken a hostile approach.
Parents left without answers
For parents, the consequences of those failures extended far beyond the period in which their children were treated. The inquiry found that families were kept unaware for years that there might have been concerns their babies had been deliberately harmed.
Thirlwall called the treatment of parents “reprehensible”. Hospital executives used the possibility of upsetting families as an argument against informing them and against bringing concerns to the police, despite the importance of safeguarding other babies and ensuring a proper investigation.
The findings underline why unusual clinical events must be examined collectively, rather than treated as separate incidents. The inquiry’s conclusions also stress the need for staff at every level to raise concerns, record them clearly and act where a patient may face continuing risk.
At the centre of the inquiry are families whose children died or suffered serious harm. The report sets out not only the crimes for which Letby was convicted, but also the institutional decisions and missed chances that allowed warning signs to go unanswered for too long.
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