- Published
Mention Lucy Letby and you're likely to get a strong reaction.
asserted
you → publish → reaction
The nurse was sentenced to spend the rest of her life in prison for murdering seven babies and attempting to murder seven more.
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nurse → sentence → seven
But though two juries have convicted her, and she has twice been denied permission to appeal, it seems everyone has an opinion on whether she really did it.
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she → convict → it
She has become the centre of an information war.
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She → become → war
The name Lady Justice Thirlwall, however, attracts less recognition.
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name → attract → recognition
She's the judge who's been tasked with examining how Letby was able to commit her crimes at the Countess of Chester Hospital in 2015-2016, and whether her managers should have responded differently when suspicions about her were raised.
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suspicions → task → her
After months of hearings, the findings of her inquiry will be published on Tuesday, almost a year later than originally anticipated.
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findings → publish → Tuesday
So will the Thirlwall Report change the conversation about Lucy Letby?
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Report → change → Letby
Will people who have entrenched views about her change their mind as a result?
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who → have → result
The report won't change the narrative about Letby's guilt or innocence because it didn't examine that subject at all.
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it → change → subject
Lady Justice Thirlwall said she had "approached the inquiry on the basis that Lucy Letby is guilty of the crimes of which she has been convicted".
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she → say → which
She emphasised that it was not her role "to set about reviewing the convictions", telling the inquiry: "The Court of Appeal has done that, with a very clear result."
But there is also a longer, more complex answer.
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Court → emphasise → result
Whatever the report's conclusions, Letby's convictions will stand.
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convictions → stand → ?
However, the inquiry hasn't operated in a vacuum.
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inquiry → operate → vacuum
There are other parts of the legal system which will have an eye on its findings.
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which → be → findings
And the chairwoman of the Criminal Cases Review Commission (CCRC) - the only organisation with the power to send Letby's case back to the Court of Appeal - has told the BBC the CCRC will be paying close attention to Thirlwall.
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CCRC → send → Thirlwall
Dame Vera Baird said: "We will be looking at the report with interest to assess whether it has any bearing on our review of the case."
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it → say → case
The CCRC has given no indication of when it will make its decision.
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it → give → decision
But while questions over Letby's convictions weren't within the scope of the Thirlwall Inquiry, it didn't stop the subject making itself felt within the hearing room.
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itself → stop → room
Just as the inquiry was wrapping up, the hospital's former executives applied for it to be delayed until the CCRC has made its decision.
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CCRC → wrap → decision
Letters pushing for a delay were also written to the inquiry by Letby's lawyers and Sir David Davis, an MP who has campaigned on her behalf.
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who → push → behalf
Sir David argued that an inquiry "predicated on the presumption that Lucy Letby's conviction is safe, when there is now a wealth of authoritative voices questioning that conviction, will only undermine the conclusions arrived at by your inquiry and potentially lead to more babies dying unnecessarily".
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babies → argue → inquiry
Lady Justice Thirlwall refused the requests to pause the inquiry.
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Thirlwall → refuse → inquiry
She said that she was not scrutinising Letby's actions, but those of the officials and managers who were responsible for responding to the crisis.
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who → say → crisis
The families of babies whom Letby has been convicted of murdering and attempting to murder did not want the inquiry to be paused.
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inquiry → convict → whom
Richard Scorer from Slater & Gordon Solicitors, who represents three of the families, told the BBC that the fact that Letby's convictions still stand is crucial.
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convictions → represent → BBC
"That's the legal reality," he said.
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he → say → ?
"And the noise about her convictions doesn't change that."
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noise → change → that
But he added that, irrespective of Letby's convictions, "serious failures" at the hospital – and the way in which managers handled concerns as they emerged – must not be repeated elsewhere.
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they → add → concerns
So, what is the Thirlwall report likely to tell us?
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report → tell → us
The questions the report may answer
The most stark question it may answer is whether any babies might have lived, or avoided injury, if action had been taken earlier.
The inquiry released thousands of documents which shed new light on what was going on inside the hospital.
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what → answer → hospital
When the hearings finished, we put together this timeline which illustrates how events unfolded.
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events → finish → timeline
Should alarm bells have started ringing as early as June 2015 when three babies died in quick succession – the same number of deaths within two weeks that the unit would normally expect in a year?
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unit → start → year
What about in August 2015, when a baby was poisoned with insulin?
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baby → poison → insulin
The results of his blood test didn't raise an alert.
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results → raise → alert
At the inquiry, hospital consultants accepted this had been a "collective failure".
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this → accept → inquiry
Lawyers for the baby's family said the test results "provided the clearest opportunity to detect and stop Letby" and were "a bright line within the chronology after which no babies should have been harmed".
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babies → say → which
By early 2016, senior managers including medical director Ian Harvey and director of nursing Alison Kelly knew there was an unusually high death rate on the neonatal unit and that there were escalating concerns about a nurse.
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managers → include → nurse
But it didn't lead to safeguarding action.
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it → lead → action
It was only after two triplet brothers died in June 2016 that Letby was taken off nursing duty.
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Letby → die → duty
…and 37 more, not listed.
The Aporia
