The Thirlwall Inquiry has published its findings into how concerns about Lucy Letby were handled at the Countess of Chester Hospital. The report examines whether action could have been taken sooner, including whether earlier intervention might have prevented further deaths and harm, while also considering the hospital’s leadership and handling of concerns.
A public inquiry into events at the Countess of Chester Hospital has concluded that some infants could have been saved and various attacks prevented if earlier, decisive action had been taken regarding concerns about neonatal nurse Lucy Letby. The inquiry examined staff and leadership conduct spanning from Letby’s employment in 2012 to her removal from the neonatal unit in 2016.
Lady Justice Thirlwall stated there was a "complete failure" to protect the infants under the unit's care. She determined that the hospital's management and governance were dysfunctional, noting a significant divide between hospital leadership and clinicians. Furthermore, the report indicates that staff failed to recognize that safeguarding measures were necessary when a member of the medical team was suspected of intentionally harming babies.
The inquiry specifically addressed the case of an infant whom Letby attempted to murder through insulin poisoning in August 2015. Lady Justice Thirlwall observed that had the results of that incident been acted upon appropriately, reporting the matter to the police would have been unavoidable. Although Letby was moved to administrative duties in July 2016, the inquiry found that Cheshire Constabulary was not invited to investigate the situation until May 2017.
The report also revealed that parents were kept in the dark regarding these suspicions until Letby’s arrest and subsequent contact with families in July 2018. To address these systemic failures, the inquiry has issued 14 recommendations, including the implementation of baby monitors in neonatal cots and incubators, enhanced CCTV coverage focused on insulin storage, and stricter controls over access to insulin.
Investigations into potential corporate and gross negligence manslaughter related to these events remain ongoing.
