Lucy Letby is serving 15 whole-life terms for the murders of seven babies and attempted murders of seven others.
The deaths of three babies at the hands of Lucy Letby could have been prevented if police were called in sooner, an inquiry prompted by the child serial killer’s crimes has found.
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.
Publishing her final 822-page report on Tuesday, Lady Justice Thirlwall said: “There was a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital.
“This was because 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.
“My report describes dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals of safeguarding.”
Lady Justice Thirlwall, one of the country’s most senior judges, said: “There was complete failure at all levels to invoke safeguarding procedures at any point.
“Once there was suspicion that Letby may be causing harm deliberately safeguarding steps should have been taken.
“She should have been removed from the ward as a neutral act and matters could have been investigated without risk to babies.
“No-one seems to have thought that safeguarding action is required when a member of staff is suspected of causing deliberate harm. Suspicion is enough.”
Contacting the police would have been “unavoidable”, Lady Justice Thirlwall said, if the deliberate poisoning by insulin of a baby boy, Child F, in August 2015 had been recognised at the time by medics
Suspicions became clearer after the October 2015 death of Letby’s fifth murder victim, Child I, and the nurse should have been removed from the neonatal unit at this point, the report found.
Lady Justice Thirlwall said: “This did not happen. The collapses and deaths continued.”
Letby went on to attempt to murder Child K in February 2016, Child L and M in April 2016 and Child N in June 2016. She murdered Child O and Child P later in June 2016.
An important meeting in May 2016 took place in which concerns were raised to senior managers about the high mortality rate and the commonality of the presence of a specific nurse.
Safeguarding was not considered at the meeting, the inquiry found, and Letby remained on the ward.
Lady Justice Thirlwall said: “This should not have happened, and babies O and P should not have died.”
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.
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.
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.
The Thirlwall report found that senior nurses never accepted that the consultants’ concerns were, or might be, justified, and that there was a prolonged delay by senior managers in calling the police.
It ruled that successive internal and external reviews commissioned by hospital leadership after concerns were raised about Letby did not address whether deliberate harm was being caused or not.
The chairwoman also ruled that parents of Lucy Letby’s victims were “kept in the dark” about suspicions by the hospital.
The inquiry chairwoman said: “The anger some parents feel at the way they were treated by the Countess was palpable.
“They were kept in the dark for years about what was happening, about the fact that there were concerns that their babies may have been deliberately harmed
“They were not informed about reviews and only in 2018 learned that the collapses and deaths may have been the result of the actions of a nurse whom they had trusted.
“The lack of consideration shown to the parents at that time was reprehensible.”
A total of 14 recommendations have been made in the report, including the fitting of baby monitors in all cots and incubators in neonatal units, and CCTV cameras focused on insulin storage fridges.
Lady Justice Thirlwall said baby monitors would ensure parents could observe their babies “remotely at any time” – adding that NHS England should “set out a roadmap” for how it could be implemented by March 31 next year.
She also said digital devices should be used to “restrict access of insulin to authorised people”, as well as record access to insulin units.
Health Secretary Yvette Cooper called for the publication of the Thirlwall report to be “a turning point for the NHS” and said “the safeguarding and wellbeing of babies must never again be treated as a side issue”.
She said she has asked officials to develop plans to install “cot cams” in neonatal units and the Government has agreed to strengthen controls on insulin storage
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.
She was twice denied permission to appeal against her convictions in 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.
A court order prohibits reporting of the identities of the surviving and dead children involved in the case.
Investigations by Cheshire Constabulary into potential offences of corporate manslaughter and gross negligence manslaughter remain ongoing.
Inquests into the deaths of babies who Letby was convicted of murdering are to take place in May 2027.
