An inquiry into how neonatal nurse Lucy Letby was able to harm and kill babies at Countess of Chester Hospital has found major failures in management, governance, and protection systems. The investigation was led by Lady Justice Kathryn Thirlwall and has cost more than £18 million. It concluded that two baby deaths would have been avoided if Letby had been removed from clinical duties earlier and said a third baby might have survived if an earlier insulin-poisoning result had been acted upon. The inquiry said the precise number of deaths that could have been prevented will never be known.
The report also described troubling behavior by Letby, including a shouting match with her supervisor, according to thesun.ie. Letby was found guilty in 2023 of murdering seven babies and attempting to murder six more. She was convicted in a 2024 retrial of attempting to murder a seventh baby. The inquiry found that a lack of communication and trust between doctors and nurses contributed to the failure.
It noted that the hospital’s safeguarding policy did not include guidance on how to respond if staff were suspected of causing harm. The inquiry also found that Letby falsified medical records and acted inappropriately toward patients. She was described as repeatedly untruthful with colleagues and showed callous behavior. Thirlwall said the hospital still lacked a proper understanding that safeguarding procedures must be used when deliberate harm by a staff member is suspected.
One of the babies under Letby’s care was found covered in their own waste. The inquiry found that Letby omitted important information from medical records and was repeatedly untruthful in her dealings with colleagues and others. It also found that hospital staff who supported Letby became too close to her professionally.
These supporters moved from helping her professionally to becoming personal friends. The report criticized how hospital leaders used the fear of upsetting families as a reason not to involve police. Communication with parents was also described as poor and distressing. Parents were kept unaware for years that doctors had raised concerns that their babies might have been deliberately harmed. Thirlwall described the hospital’s treatment of the families as reprehensible.
The inquiry was launched in 2023, following Letby’s convictions. Lady Justice Thirlwall heard evidence and submissions during public hearings between September 2024 and March 2025. The inquiry aimed to answer questions for the families of victims and to learn lessons from past cases. The final report was published on September 15, 2026.
It referenced a similar case from decades ago involving nurse Beverley Allitt. Lady Justice Thirlwall said the hospital had a breakdown in leadership and understanding of child protection. She emphasized that there was a total failure to protect the babies on the neonatal unit. The report also criticized senior nurses for failing to accept that concerns raised by doctors might have been justified and senior managers for waiting too long to contact police.
The inquiry recommended installing cameras on every baby cot and incubator to help prevent future harm. The recommendation calls for all neonatal cots and incubators to have baby monitors with livestreaming video so parents can remotely see their babies. It also urged the entire NHS to adopt a protocol that treats any suspicion of deliberate harm as serious. The report said hospital managers should not be allowed to ignore concerns anymore. Thirlwall made 17 recommendations covering areas including monitoring, insulin security, safeguarding and oversight of deaths.
Letby continues to maintain that she was wrongly convicted, but the Thirlwall Inquiry did not reconsider her guilt or innocence. It conducted its work on the basis of the convictions that remain in force. Letby’s legal team has asked the Criminal Cases Review Commission to examine the convictions and the commission says its review is underway. The CCRC can refer a case to the Court of Appeal if it decides there is a real possibility that a conviction will not be upheld.
The findings show that the hospital system failed in many ways to protect vulnerable children, The Seattle Times reported. The inquiry found that there was a complete failure to protect babies on the neonatal unit. Thirlwall said staff and managers failed to understand that safeguarding action was required when a member of staff was suspected of deliberately harming patients.
Prosecutors recently decided that evidence against Letby was not strong enough to bring further charges. The Crown Prosecution Service reconsidered six possible attempted-murder charges after families requested a review. In August, the CPS upheld its earlier decision not to bring additional charges because its evidential test was not met.
IMAGE: Lady Justice Kathryn Thirlwall, a judge of the Court of Appeal of England and Wales. Photo: Judicial Office, England & Wales / Wikimedia Commons, July 19, 2019, OGL 3.0.