- Published
The public inquiry into how serial killer Lucy Letby was able to murder babies at the Countess of Chester hospital has delivered its findings, describing a "complete failure" to protect infants from harm.
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Letby → publish → harm
After hearing from more than 130 witnesses, and considering 400 statements over six months, the Thirlwall Inquiry report was published earlier at Liverpool Town Hall.
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report → hear → Hall
The inquiry began in September 2024, after Letby was convicted of murdering seven babies and attempting to murder seven others - one of whom she attempted to kill twice.
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she → begin → whom
Below are the key findings from Lady Justice Thirlwall's report, which ran to more than 1,100 pages over three volumes.
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which → run → volumes
Hospital 'missed opportunities' to prevent murders
The first three deaths in June 2015 (babies A, C and D) were not viewed as a cluster of deaths, even though this was the annual number of deaths, concentrated into two weeks.
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this → miss → weeks
The fourth death, (Baby E) in August 2015, was unexpected and therefore reviewed at a serious incident panel meeting attended by the medical director and director of nursing - but it was treated as a formality.
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it → review → formality
"What is surprising is that no connection was made by any of the people involved to the earlier deaths," Thirlwall noted.
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Thirlwall → make → deaths
By August of that year, the total of four deaths was the highest since 2008, and was to double by the end of the year.
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total → double → year
Thirlwall found that if a doctor – named in the report as Dr ZA - had not disregarded the insulin test result for Baby F in August 2015 then there should have been safeguarding action.
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doctor → find → August
The report also found:
The safeguarding action would have prevented the attacks on babies G and H, J, K, L, M and N and the deaths of Baby I, O and P
If safeguarding action had been taken by October 2015 - after the death of Baby I - by moving Letby off the ward, the deaths of babies O and P would have been prevented, as would the attacks on babies J, K, L, M and N
In February 2016, Dr Ravi Jayaram should have reported what he had seen with regard to Baby K
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he → find → K
In May 2016, no one raised safeguarding at a meeting with execs - if they had done it would have prevented the deaths of babies O and P
Thirlwall found there was a "complete failure to protect babies on the neonatal unit" at the Countess of Chester Hospital, where Letby, now 36, murdered seven babies and attempted to murder seven others, one of them twice.
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Letby → raise → them
She described a system of "dysfunctional management and governance".
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She → describe → management
Executives tried to 'control the narrative'
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Executives → try → narrative
Thirlwall found hospital bosses repeatedly failed in their duty of candour with parents, investigators and regulators.
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bosses → find → parents
She added their behaviour was "high-handed, against all safeguarding principles, and foolhardy".
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behaviour → add → principles
Medical director Ian Harvey "sought to control the narrative", and presented the case as he saw it.
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he → seek → it
He made sure that only documents that supported his case were seen, if necessary writing them himself.
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that → make → them
The report also found:
Director of nursing Alison Kelly, the head of safeguarding, knew she had to act when there was a suspicion that a baby had been harmed, and others might be at risk – but did not
Chief executive Tony Chambers was dictatorial in his approach to consultants, and executive presentations to the hospital's board were an "exercise in spin"
He added to the unnecessary delay in contacting police
His intention throughout was to stall or obstruct the police investigation, which he succeeded in doing for almost a year
The report was critical of a raft of internal and external reviews commissioned by hospital leadership after concerns were raised about Letby
Director of nursing for urgent care Karen Rees had "lost all judgement" and had a "hostile approach", Thirlwall found.
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Thirlwall → find → approach
She also found that unit manager Eirian Powell's judgement "was affected by the view that Letby was a very good nurse".
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Letby → find → view
'Toxic negativity' towards whistleblowers
Thirwall found wider NHS failings played their part, with a tendency across the health service for management to become pre-occupied with avoiding blame and focusing on reputation management.
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management → find → management
She said there was still a "toxic negativity" that discouraged people within the NHS from speaking out, even though efforts had been made over the last decade to strengthen protections for whistleblowers.
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efforts → say → whistleblowers
Regulation was also found to be lacking.
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Regulation → find → ?
The Care Quality Commission (CQC) inspected the Countess of Chester in February 2016 but Letby carried on attacking babies until June of that year.
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Letby → inspect → year
Key information was withheld from inspectors, but the regulator was criticised for not showing enough curiosity to look beyond what it was being told, even though the CQC had been warned by the inquiry into baby deaths at Morecambe Bay NHS Trust that it needed to take a tougher approach.
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it → withhold → approach
Parents were treated 'reprehensibly'
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Parents → treat → ?
The parents of babies were "kept in the dark for years" over concerns that their children may have been deliberately harmed.
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children → keep → concerns
Thirlwall found their treatment to be "reprehensible", and said hospital executives used the risk of upsetting the parents as a convenient argument to justify not calling the police.
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executives → find → police
In relation to the treatment of doctors, she said it should "never have been about nurses against doctors… it was about keeping babies safe".
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it → say → babies
Doctors were found not to have been given the protection of the Speak Out Safely whistleblowing policy, and senior managers tried to "manage out" consultants, and suggested they might be referred to the General Medical Council watchdog.
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they → find → watchdog
Letby took out a grievance against the hospital in 2017, after being moved off her normal duties amid allegations about her.
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Letby → take → her
The report found that "the way Letby's grievance and its consequences were handled was deplorable", adding that the investigating officer in charge "could bring neither independence nor objectivity to it".
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officer → find → it
The evidence of Alison Kelly and Ian Harvey was found to be "factually inaccurate and misleading", and the chair of the governance panel, Annette Weatherly, was "unfair in her approach", having initially described the allegations against Letby as a "witch hunt".
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chair → find → hunt
Letby falsified records and ignored instructions
Police were called into the hospital in 2017.
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Police → falsify → 2017
Thirlwall added "no-one seems to have understood that safeguarding action is required when a member of staff is suspected of causing deliberate harm - and does not require colleagues to be sure of guilt".
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member → add → guilt
She said safeguarding guidance "makes no difference" if "those to whom concerns are expressed do nothing".
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concerns → say → nothing
The report found Letby had ignored management instructions when she disliked them and shouted at her manager.
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she → find → manager
She had falsified records and one infant in her care had been found covered in their own faeces.
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infant → falsify → faeces
She was also found to have been repeatedly untruthful in her dealings with friends and colleagues, and was noted by patients to have been "inappropriate" and "callous" in her manner.
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She → find → manner
Access to insulin 'should be restricted'
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Access → restrict → insulin
Thirlwall made 17 recommendations in her report, which ran to over 1,100 pages over three volumes.
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which → make → volumes
…and 2 more, not listed.
The Aporia
