Key facts
- The Thirlwall Inquiry found a "complete failure to protect babies on the neonatal unit" at the Countess of Chester Hospital.
- Hospital bosses repeatedly failed in their duty of candour with parents, investigators, and regulators.
- If safeguarding action had been taken by October 2015, the deaths of babies O and P, and attacks on babies J, K, L, M and N would have been prevented.
- Medical director Ian Harvey "sought to control the narrative" and presented the case selectively.
- Chief executive Tony Chambers' approach was described as "dictatorial", and executive presentations to the board were an "exercise in spin".
- Parents were "kept in the dark for years" and their treatment was described as "reprehensible".
An independent 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. The report, published at Liverpool Town Hall, was launched in September 2024 after Letby was convicted of murdering seven babies and attempting to murder seven others. Lady Justice Thirlwall's report, spanning over 1,100 pages, highlighted that the first three deaths in June 2015 were not viewed as a cluster, despite being the annual number of deaths concentrated into two weeks. The fourth death in August 2015 was reviewed but treated as a formality, with no connection made to earlier deaths. The report found that if a doctor, identified as Dr ZA, had not disregarded an insulin test result for baby F in August 2015, safeguarding action should have been taken. This action would have prevented attacks on babies G, H, J, K, L, M, and N, and the deaths of babies I, O, and P. If Letby had been moved off the ward by October 2015, after the death of baby I, further deaths and attacks would have been prevented. Hospital bosses were found to have repeatedly failed in their duty of candour, with their behaviour described as "high-handed, against all safeguarding principles, and foolhardy." Medical director Ian Harvey "sought to control the narrative," presenting the case as he saw fit and ensuring only supportive documents were seen. Director of nursing Alison Kelly, the head of safeguarding, knew she had to act on suspicions of harm but did not. Chief executive Tony Chambers was described as "dictatorial," and executive presentations to the board were an "exercise in spin," contributing to unnecessary delays in contacting the police. Director of nursing for urgent care Karen Rees had "lost all judgement" and had a "hostile approach," while unit manager Eirian Powell's judgement was "affected by the view that Letby was a very good nurse." The report also noted wider NHS failings, including a "toxic negativity" that discouraged whistleblowers, and a lack of regulatory oversight. The Care Quality Commission (CQC) inspected the hospital in February 2016 but key information was withheld, and the regulator was criticized for not being curious enough despite prior warnings. Parents were "kept in the dark for years," and their treatment was deemed "reprehensible," with executives using the risk of upsetting them as justification for not calling the police. Doctors who raised concerns were not adequately protected by whistleblowing policies, and senior managers attempted to "manage out" consultants. Letby took out a grievance against the hospital in 2017 after being moved from her duties amid allegations. The report found the handling of this grievance was "deplorable," with the investigating officer lacking independence and objectivity. Evidence from Kelly and Harvey was found to be "factually inaccurate and misleading," and the chair of the governance panel, Annette Weatherly, was "unfair in her approach," initially describing the allegations as a "witch hunt." Police were called in 2017, but the report highlighted a lack of understanding regarding safeguarding action when deliberate harm is suspected. Letby ignored management instructions, shouted at her manager, falsified records, and was noted by patients to be "inappropriate" and "callous." Lady Justice Thirlwall made 17 recommendations, including fitting neonatal unit cots and incubators with baby monitors and restricting access to insulin.