Thirlwall Inquiry: Baby deaths in Letby case could have been prevented
A public inquiry into nurse Lucy Letby's crimes has found that some baby deaths and attacks could have been prevented had hospital safeguarding rules been followed. The report describes dysfunctional management and executives who obstructed the truth.
The public inquiry into the crimes of nurse Lucy Letby has concluded that some of the deaths and near-fatal attacks on babies at the Countess of Chester Hospital's neonatal unit could have been prevented if safeguarding procedures had been followed. Letby, now 36, was convicted of murdering seven babies and attempting to murder seven others, one of them twice.
Inquiry chair Lady Justice Thirlwall described a "complete failure to protect babies" on the unit and a system of "dysfunctional management and governance." While she said it would never be possible to know exactly how many lives could have been saved, she identified specific missed opportunities — including a disregarded insulin test result in August 2015 and a failure to remove Letby from the ward after a baby's death in October 2015 — that, had they been acted on, would have prevented further deaths and attacks.
Executives criticised
The report is sharply critical of hospital leadership. Medical director Ian Harvey was found to have sought to control the narrative, ensuring only documents supporting his position were seen. Director of nursing Alison Kelly knew she needed to act on suspicions a baby had been harmed but did not. Chief executive Tony Chambers was described as dictatorial toward consultants and was found to have contributed to delaying the police investigation by almost a year.
Parents were said to have been kept in the dark for years over suspicions their children may have been deliberately harmed, conduct the inquiry called "reprehensible." Doctors, meanwhile, were not properly protected by whistleblowing policy, and senior managers attempted to "manage out" consultants who raised concerns.
Lady Justice Thirlwall issued 17 recommendations in her report, including fitting neonatal cots and incubators with baby monitors and restricting access to insulin — which Letby used to poison two babies — through biometric data or CCTV monitoring. Letby was sentenced to 14 whole life terms in 2023, with an additional term added in 2024 after a retrial on a further attempted murder charge.
