The Thirlwall Inquiry was launched in 2023 in the wake of the former nurse’s multiple convictions for murder and attempted murder of infants at the Countess of Chester Hospital.
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Inquiry → launch → Hospital
One of the country’s most senior judges, Lady Justice Thirlwall, heard evidence at Liverpool Town Hall from numerous witnesses between September 2024 and February 2025, including from the parents of Letby’s victims.
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One → hear → victims
The inquiry’s key objectives were to seek answers for the victims’ families and ensure lessons are learned – some 25 years after another nurse, Beverley Allitt, committed similar crimes on a children’s ward in Grantham, Lincolnshire.
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nurse → seek → Grantham
Lady Justice Thirlwall noted that an inquiry had also taken place into events surrounding Allitt’s killing spree and said it was “utterly unacceptable” it had happened again within the NHS.
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it → note → NHS
Her investigation did not examine Letby’s convictions or motives but instead focused on the conduct of those working at the Countess of Chester, including the board, managers, doctors and nurses from when Letby started her employment in 2012.
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Letby → examine → 2012
Letby, 36, was moved from the neonatal unit to administrative duties in July 2016 after consultants expressed concerns about her to the hospital’s executive team.
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consultants → move → team
Hospital bosses opted to carry out a number of reviews into the increased mortality in 2015 and 2016, and did not invite Cheshire Constabulary to investigate until May 2017, as Letby remained on site until her arrest more than a year later.
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Letby → opt → arrest
The inquiry examined whether suspicions should have been raised earlier and whether the police and other external bodies should have been informed sooner.
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police → examine → ?
It looked at the response to concerns about Letby and whether the culture, management and governance structures and processes of the hospital trust, and the wider NHS, contributed to the failure to protect babies from Letby.
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culture → look → Letby
The inquiry also heard evidence about whether the accountability of senior managers should be strengthened.
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accountability → hear → managers
Sir Robert Francis, who chaired the inquiry into chronic care failings at Mid Staffordshire NHS Foundation Trust, told Lady Justice Thirlwall there was no regulator “with teeth” to impose sanctions on poorly performing non-clinical directors.
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who → chair → directors
Letby, from Hereford, who maintains her innocence, is serving 15 whole-life terms for the murders of seven babies and attempted murders of seven others by various means between June 2015 and June 2016.
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who → maintain → June
She was twice denied permission to appeal against her convictions in 2024.
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She → deny → 2024
The Criminal Cases Review Commission, which investigates potential miscarriages of justice, is considering evidence presented on her behalf by an international panel of medics who claim poor medical care and natural causes were the reasons for the babies collapsing.
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babies → investigate → medics
A number of doctors, scientists and statisticians have publicly challenged the way the evidence was presented to jurors at her trial.
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evidence → challenge → trial
Last year, Lady Justice Thirlwall rejected separate applications from Letby and the Countess of Chester’s former senior management team to pause her inquiry pending the outcome of Letby’s bid to clear her name.
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Thirlwall → reject → name
Solicitors representing Letby wrote to her with concerns that the final report would “not only be redundant but likely unreliable”, and if the convictions were overturned, would be “based on the wrong premise”.
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convictions → represent → premise
However legal teams for the families of Letby’s victims said it was yet another “cynical attempt” by the former nurse to control the narrative and that the executives wanted to avoid criticism.
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executives → say → criticism
They added there was “nothing remarkable or new” about the evidence presented by the international panel of medics.
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They → add → medics
Richard Scorer, head of abuse law and public inquiries at Slater and Gordon and lawyer for three of the families of Letby’s victims, told Times Radio on Tuesday that the hospital system had “very badly let down” parents and families.
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system → tell → parents
“In addition to that, there’s the whole issue of the duty of candour, and the failure of the hospital to be candid with parents about what was really going on, which went on over a very long period of months and years,” he said.
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he → ’ → months
Mr Scorer added he felt it was “inevitable” there would be culpability attributed to both individuals involved in the hospital’s response and the hospital as an institution.
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it → add → institution
“What we’ve got to ensure is that these kinds of mistakes are not repeated in future cases if they should happen,” he said.
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he → get → cases
“That means ensuring that there are mandatory procedures that have to be followed in this kind of situation and that there is a much-strengthened duty of candour within the NHS.”
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that → mean → NHS
A court order prohibits reporting of the identities of the surviving and dead children involved in the case.
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order → prohibit → case
Investigations by Cheshire Constabulary into potential offences of corporate manslaughter and gross negligence manslaughter remain ongoing.
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Investigations → remain → manslaughter
Inquests into the deaths of babies who Letby was convicted of murdering are to take place in May 2027.
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Letby → convict → May
The Aporia
