Key facts
- The Thirlwall report will not review Lucy Letby's convictions, as her guilt is presumed.
- The inquiry will focus on the actions of officials and managers responsible for responding to the crisis.
- The Criminal Cases Review Commission will review the Thirlwall report for any bearing on its case review.
- Hospital consultants accepted there was a 'collective failure' regarding a baby poisoned with insulin in August 2015.
- Senior managers knew of an unusually high death rate and escalating concerns about a nurse by early 2016.
- Letby was removed from nursing duty only after two triplet brothers died in June 2016.
The findings of Lady Justice Thirlwall's inquiry into the Lucy Letby case will be published on Tuesday, examining how the nurse was able to commit her crimes and whether hospital management responded adequately to suspicions. The report is not intended to review Letby's convictions, which Lady Justice Thirlwall stated were not within the inquiry's remit, emphasizing that the Court of Appeal had already upheld them.
Despite the inquiry's focus, the Criminal Cases Review Commission (CCRC), which can refer cases back to the Court of Appeal, will be closely monitoring the report's conclusions. Dame Vera Baird, chairwoman of the CCRC, told the BBC that the commission will assess whether the report has any bearing on its ongoing review of Letby's case.
Requests to delay the inquiry until the CCRC made its decision, made by former hospital executives, Letby's lawyers, and MP Sir David Davis, were refused by Lady Justice Thirlwall. She clarified that her focus was on the systemic failures and the conduct of officials, not on Letby's guilt or innocence. Lawyers for the victims' families supported this stance, emphasizing the legal reality of Letby's convictions.
The inquiry is expected to highlight significant failures in patient safety processes at the Countess of Chester Hospital. Evidence presented suggested that alarm bells should have rung as early as June 2015, when three babies died in quick succession, and again in August 2015 when a baby was poisoned with insulin. Consultants at the hospital acknowledged this as a "collective failure."
Recommendations from the report may include new controls on insulin storage, compulsory procedures for suspected deliberate harm, clearer regulation of NHS managers, and increased use of CCTV in neonatal units. The inquiry is also expected to expose the failure to implement recommendations from over 1,400 previous healthcare-related inquiries, a phenomenon described as "the British disease."