In short:
The findings from a public inquiry into a British hospital's handling of multiple infant deaths have been released.
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findings → release → deaths
The case, which saw neonatal nurse Lucy Letby given 15 life sentences for murder and attempted murder, has made global headlines for several years.
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Letby → see → years
This inquiry did not examine Letby's guilt or trial, but rather how the UK's health system responded to the situation.
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system → examine → situation
British nurse Lucy Letby was able to murder seven babies because of a "complete failure" to protect babies at the hospital at which she worked, and some of the deaths could have been avoided, the chair of an inquiry has said.
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chair → murder → inquiry
Lady Justice Kathryn Thirlwall criticised senior staff for not acting sooner, blaming dysfunctional management at the Countess of Chester Hospital, in northern England, and a basic lack of understanding of safeguarding, when she handed down her findings on Tuesday, local time.
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she → criticise → Tuesday
Letby, 36, was convicted in 2023 of murdering seven newborns and attempting to murder six others, making her Britain's most prolific serial child killer of modern times.
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her → convict → times
She was later convicted of another attempted murder charge.
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She → convict → charge
Prosecutors said Letby attacked the newborns by giving them an overdose of insulin, injecting them with air or force-feeding them milk between June 2015 and June 2016, in a case that shocked Britain and drew worldwide attention.
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that → say → attention
But Letby, who was sentenced to life without parole and maintains she is innocent, has also been the subject of a growing campaign, backed by some medical experts and specialists, which has publicly questioned her convictions.
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which → sentence → convictions
This public inquiry was set up to examine the events at the hospital and the UK health system's handling of them, not Letby's conviction.
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inquiry → set → them
Ms Thirlwall, who previously criticised "noise" around the case, did not address Letby's guilt or innocence in her report, dealing with the Countess of Chester Hospital's response and whether suspicions should have been raised earlier.
She also emphasised the impact on those whose children were harmed, saying: "The families must not be collateral damage in the public argument about whether or not Letby is guilty.
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Letby → criticise → argument
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The contents of her report, though, will be pored over by those who assert Letby's innocence, around two dozen of whom gathered outside Liverpool Town Hall on Tuesday.
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dozen → pore → Tuesday
It will also be examined by the Criminal Cases Review Commission, an independent body that reviews potential miscarriages of justice and is considering an application from Letby's legal team.
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that → examine → team
"This inquiry has proceeded on the wrong premise and it follows that this has inevitably affected the report as a whole," Letby's lawyer, Mark McDonald, said in a statement.
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lawyer → proceed → statement
"Once there was suspicion that Letby may be causing harm deliberately, safeguarding steps should have been taken," Ms Thirlwall said as she delivered her final report.
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she → be → report
"No one seems to have thought that safeguarding action is required when a member of staff is suspected of causing deliberate harm," she added.
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she → seem → harm
She made a series of recommendations to improve neonatal services in the state-run National Health Service, calling on the government to tackle the "long-standing underfunding of hospital services for babies and children".
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She → make → babies
Thirlwall also suggested a series of measures to protect patients, including fitting cots and incubators with cameras, stronger insulin storage safeguards and an NHS protocol for when staff are suspected to have deliberately harmed a patient.
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staff → suggest → patient
Richard Scorer, a lawyer at Slater and Gordon who represents three families, said Thirlwall's recommendations should be implemented without delay.
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recommendations → represent → delay
"Far too often public inquiry recommendations are left to gather dust," he said.
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he → leave → dust
Ms Thirlwall's report was particularly critical of senior executives and nursing leaders at the Countess of Chester Hospital, saying at least two of Letby's murders could have been prevented if action was taken sooner.
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action → say → murders
Three senior hospital managers were arrested last year on suspicion of gross negligence manslaughter and remain under investigation, Cheshire Police said, with one of the three also suspected of perverting the course of justice.
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one → arrest → justice
Evidence submitted by the force in support of further charges relating to Letby's time working at the Countess of Chester Hospital and Liverpool Women's Hospital was, however, deemed to be insufficient by prosecutors last year.
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Evidence → submit → prosecutors
The Aporia
