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Thirlwall Inquiry Blames 'Complete Failure' by Hospital Bosses in Letby Baby Deaths

By Today News Hours Editorial Desk

A public inquiry into how serial killer Lucy Letby was able to murder infants at the Countess of Chester Hospital has concluded that there was a "complete failure" to protect babies from harm. Lady Justice Thirlwall's report, spanning more than 1,100 pages across three volumes, was published at Liverpool Town Hall after the inquiry heard from over 130 witnesses and reviewed 400 statements over six months.

The inquiry began in September 2024, following Letby's conviction for murdering seven babies and attempting to murder seven others, one of them twice.

The report found that the first three infant deaths in June 2015 - babies A, C and D - were not recognised as a cluster, despite matching the hospital's usual annual death toll within just two weeks. A fourth death, that of Baby E in August 2015, prompted a serious incident panel review attended by senior hospital leaders, but Thirlwall said this was treated merely as a formality, with no link made to the earlier deaths.

By August 2015, four deaths had already occurred - the highest number since 2008 - and this total would double by year's end. The inquiry found that a doctor referred to as Dr ZA disregarded an insulin test result for Baby F that month, which should have triggered safeguarding measures. Had action been taken then, it could have prevented attacks on babies G, H, J, K, L, M and N, and the deaths of babies I, O and P.

The report further found that removing Letby from the ward after the death of Baby I in October 2015 would have spared babies O and P, as well as preventing harm to babies J, K, L, M and N. In February 2016, Dr Ravi Jayaram was found to have failed to report concerns about Baby K, and in May 2016, no safeguarding issues were raised during a meeting with executives - action that could have prevented the deaths of babies O and P.

Thirlwall described a system of "dysfunctional management and governance" at the hospital, where Letby, now 36, carried out her attacks.

The inquiry also found that hospital executives repeatedly failed in their duty of candour toward parents, investigators and regulators, describing their conduct as "high-handed, against all safeguarding principles, and foolhardy." Medical director Ian Harvey was found to have "sought to control the narrative," ensuring only supportive documents were seen - sometimes writing them himself.

Director of nursing Alison Kelly, who oversaw safeguarding, was found to have known she needed to act on suspicions of harm to babies but failed to do so. Former chief executive Tony Chambers was described as dictatorial toward consultants, with board presentations characterised as an "exercise in spin." The report said Chambers contributed to delays in contacting police and intended throughout to stall the investigation, succeeding for almost a year.

Director of nursing for urgent care Karen Rees was found to have "lost all judgement" and displayed a "hostile approach," while unit manager Eirian Powell's judgement was said to have been clouded by her belief that Letby was a skilled nurse.

The inquiry also identified broader failings within the NHS, noting a tendency for management to prioritise reputation over accountability. Thirlwall said a "toxic negativity" persisted that discouraged staff from speaking out, despite recent efforts to strengthen whistleblower protections. The Care Quality Commission (CQC) was criticised for inspecting the hospital in February 2016 without sufficient scrutiny, even though key information had been withheld from inspectors - and despite earlier warnings from the Morecambe Bay inquiry that greater rigour was needed.

Parents of the affected babies were found to have been "kept in the dark for years," with their treatment described as "reprehensible." Executives were said to have used fears of upsetting parents as justification for not involving police. Thirlwall stressed that the issue should never have been framed as "nurses against doctors," but rather about protecting babies. Doctors, she found, were denied protection under the Speak Out Safely whistleblowing policy, with senior managers attempting to "manage out" consultants and threatening referrals to the General Medical Council.

After being moved from her usual duties amid suspicions, Letby filed a grievance against the hospital in 2017. The inquiry found the handling of this grievance to be "deplorable," with the investigating officer lacking independence and objectivity. Evidence given by Alison Kelly and Ian Harvey was deemed "factually inaccurate and misleading," while governance panel chair Annette Weatherly was found to have been unfair, having initially dismissed the allegations as a "witch hunt."

Police were eventually called to the hospital in 2017. Thirlwall noted that safeguarding action should be taken whenever deliberate harm is suspected, regardless of certainty of guilt, and that such guidance is meaningless if those informed take no action. The report detailed how Letby ignored management instructions, shouted at her manager, falsified medical records, and was linked to an incident in which an infant in her care was found covered in faeces. She was also found to have repeatedly lied to colleagues and friends, with patients describing her demeanor as "inappropriate" and "callous."

Thirlwall's report concluded with 17 recommendations. These include fitting cots and incubators in neonatal units with baby monitors, and restricting access to insulin - which Letby used to harm two of her victims - through biometric data or CCTV monitoring. She also called for the creation of a "suspicion of deliberate harm" policy outlining clear steps for managers, and recommended that NHS staff be contractually required to follow such safeguarding procedures.