Lucy Letby public inquiry findings set to be published
Thirlwall Inquiry report to set out lessons from Countess of Chester neonatal unit
Ninoda.com – The findings of the public inquiry into the circumstances surrounding Lucy Letby’s crimes at the Countess of Chester Hospital are due to be released on Tuesday, bringing a lengthy examination of management decisions, safeguarding and missed opportunities to act.
The Thirlwall Inquiry was established to examine events at the hospital’s neonatal unit during 2015 and 2016, when Letby was employed there as a nurse. Its central focus has not been whether Letby was guilty of the offences for which she was convicted, but how concerns about her were dealt with and whether the hospital could have intervened sooner.
Letby, 36, is serving 15 whole-life sentences after being convicted of murdering seven babies and attempting to murder seven more. One of the attempted murder victims was targeted twice. The inquiry’s conclusions are expected to address whether earlier action could have prevented deaths or injuries among babies treated on the unit.
Questions over the response to concerns
Consultants raised concerns about Letby with the hospital’s executive team before she was removed from clinical work in July 2016. She was then transferred from the neonatal unit to administrative duties. A major issue for the inquiry has been whether warning signs should have prompted a response much earlier.
Particular attention has been given to June 2015, when three babies died within a short period. The inquiry considered how unusual clinical events were identified, escalated and investigated, as well as the relationship between frontline clinicians and senior management.
Families who lost children or saw them harmed have sought a clear explanation of what happened inside the hospital and what should change as a result. The report is intended both to provide those answers and to identify measures that could improve the protection of babies in NHS neonatal services.
Six months of evidence and extensive documentation
Lady Justice Thirlwall, one of the country’s most senior judges, led the inquiry. Its evidence and submissions phase began in September 2024 and ended in March 2025. Over six months, the inquiry heard evidence and reviewed thousands of documents. The process has cost more than £18.5m.
The report had originally been expected in November 2025, but its publication was delayed several times. Those postponements have also affected the timetable for the inquests into the babies’ deaths, which are now not expected to begin until May 2027.
Its recommendations are likely to have implications beyond Chester. The inquiry has been examining systems for responding to patterns of unexpected incidents, handling staff concerns and ensuring that patient-safety issues reach the people able to make decisions. Any proposed reforms could influence practices across the NHS.
The inquiry arrives roughly 25 years after Beverley Allitt committed comparable offences on a children’s ward in Grantham, Lincolnshire. That earlier case led to scrutiny of clinical safeguards, making the current inquiry’s task especially significant: it must consider why protections and escalation processes did not prevent or halt the events at the Countess of Chester sooner.
Convictions are outside the inquiry’s remit
The inquiry was not created to revisit the criminal case against Letby. Its remit concerns institutional actions, oversight and safeguarding rather than the legal correctness of the convictions. However, the report will be closely followed by the Criminal Cases Review Commission, the body that can refer a case back to the Court of Appeal.
Letby has previously been refused permission to appeal her convictions twice. Her defence lawyer, Mark McDonald, has said he submitted nearly 30 expert reports to the CCRC which, in his view, challenge the safety of the convictions.
“If she is innocent, as I believe, as 30-odd experts believe, then everything that has gone before the inquiry and every recommendation has operated on the wrong premise.”
McDonald also responded to the departure of two experts from Letby’s defence team. Professor Geoff Chase of the University of Canterbury in New Zealand and chemical engineer Helen Shannon withdrew after saying that elements of evidence being advanced were inconsistent with the available evidence and science.
“We think our argument’s better than your argument and therefore we’re coming out of it.”
McDonald said he was sorry to see them leave and maintained that they still believed Letby was innocent. The inquiry’s findings will not determine any CCRC decision, but they may form part of the broader material considered as the commission assesses the case.
Separate police investigation continues
The report will be published while a separate police investigation involving former hospital leaders remains ongoing. In July 2025, three former senior members of staff at the Countess of Chester Hospital were arrested on suspicion of gross negligence manslaughter.
The suspects had been part of the hospital’s senior leadership team between 2015 and 2016 and remain on police bail. Cheshire Police opened an investigation into possible corporate manslaughter at the hospital in 2023, before widening it in March 2025 to include gross negligence manslaughter.
One former senior staff member was arrested again in April on suspicion of perverting the course of justice. No charges have been brought.
For families, staff and the wider health service, the Thirlwall report will be more than an account of past failures. Its value will rest on whether it clearly identifies why concerns did not produce earlier action and whether its recommendations lead to practical, lasting safeguards for vulnerable newborn babies.
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