British nurse Lucy Letby was able to murder seven newborn babies because the hospital where she worked failed “completely” to protect them, and some of the deaths might have been prevented, the chair of an inquiry has found.
Inquiry chair Kathryn Thirlwall condemned senior staff for failing to intervene sooner, pointing to dysfunctional leadership at the Countess of Chester Hospital in northern England and a fundamental misunderstanding of safeguarding responsibilities.
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Letby, 36, was convicted in 2023 of murdering seven babies and trying to murder six others, making her the most prolific serial child killer in modern British history.
She was later convicted of a further attempted murder.
Letby was sentenced to life in prison without the possibility of parole and continues to maintain her innocence. At the same time, a growing campaign supported by some medical experts and specialists has publicly challenged the convictions.
Ms Thirlwall, who has previously criticised the “noise” surrounding the case, did not assess whether Letby was guilty or innocent. Her report instead examined how the Countess of Chester Hospital responded to concerns and whether suspicions should have been acted on sooner.
Justice Thirlwall (L) and inquiry team members seen arriving earlier for the publication of the Thirlwall inquiry
“My focus has been on the questions asked in the (inquiry’s) terms of reference, not on the guilt of Lucy Letby or on her convictions,” Ms Thirlwall said.
However, those who argue that Letby was wrongly convicted are expected to scrutinise the report, as will the Criminal Cases Review Commission, the independent body that examines possible miscarriages of justice and is considering an application from Letby’s legal team.
Report criticises failure to act
“Once there was suspicion that Letby may be causing harm deliberately, safeguarding steps should have been taken,” Ms Thirlwall said while presenting her final report.
She added: “No one seems to have thought that safeguarding action is required when a member of staff is suspected of causing deliberate harm. Suspicion is enough.”
Her report sets out a series of recommendations for improving neonatal care across the state-run National Health Service, including a call for the government to address the “long-standing underfunding of hospital services for babies and children”.
Ms Thirlwall also proposed measures intended to strengthen patient protection, including cameras for cots and incubators, tighter controls over insulin storage and an NHS-wide protocol for cases in which staff are suspected of deliberately harming a patient.
Senior executives and nursing leaders at the Countess of Chester Hospital came in for especially strong criticism. The report said at least some of Letby’s crimes might have been prevented had the hospital responded earlier.
Letby was convicted of murdering seven babies and attempting to murder six others at the Countess of Chester Hospital between June 2015 and June 2016
Three senior hospital managers were arrested last year on suspicion of gross negligence manslaughter and remain under investigation, Cheshire Police said. One of the three is also suspected of perverting the course of justice.
However, evidence submitted by police in support of further charges linked to Letby’s work at the Countess of Chester Hospital and Liverpool Women’s Hospital was judged insufficient by prosecutors last year.
Parents of Lucy Letby’s victims ‘kept in the dark’ about suspicions
The inquiry found that the parents of Letby’s victims were not told about the hospital’s suspicions.
Ms Thirlwall said families did not learn of the concerns until Letby was arrested and police contacted them in July 2018.
The Thirlwall Inquiry concluded that parents had been “kept in the dark for years about what was happening and about the fact that there were concerns that their babies may have been deliberately harmed”.
Ms Thirlwall said the hospital made “the wrong call” by failing to keep parents informed about the police investigation.
She said: “Once the police were investigating the circumstances of the deaths of and injuries to their babies, the parents had the right to know about it.
“They should have been informed.”
A number of protesters in support of Lucy Letby took part in a demonstration outside Liverpool Town Hall where the report was being released
In July 2016, the mother of baby C learned of a review by the Royal College of Paediatrics and and Child Health (RCPCH), launched after deaths on the neonatal unit increased, when a friend alerted her to an article in the local newspaper, the inquiry heard.
Hospital staff told her the review was a “formality” prompted by only a small rise in deaths, she said.
Ms Thirlwall wrote in her report: “This was not a question of balance, Mother C was being misled.
“It was not a question of not getting the communication right; it was about not being straight with parents who had the right to know what was going on.”
The inquiry heard that some parents believed the hospital was more focused on protecting its reputation than on protecting their children.
The mother of baby I said: “They shouldn’t have been concentrating on saving their own skins and jobs and reputations.
“Babies died because someone in an office being paid hundreds of thousands of pounds didn’t want the hospital to look bad if they shut.”
Ms Thirlwall said: “No one could disagree with any of these observations.”
Her report described the lack of consideration shown to the parents at the time as “reprehensible”.
Medical director Ian Harvey told the inquiry that the hospital’s communication with families about a report prepared by consultant neonatologist Dr Jane Hawdon was “both crass and inappropriate”.
Ms Thirlwall said: “This was a complete apology for the abject failure of communication with the parents in respect of Dr Hawdon’s report.”
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Additional reporting PA
