The deaths and near-deaths of infants attacked by nurse Lucy Letby could have been prevented if safeguarding practices had been followed, a public inquiry has found. Lady Justice Thirlwall, chairwoman of the inquiry, stated that it would never be possible to know for sure how many lives could have been saved, but concluded there was a "complete failure to protect babies on the neonatal unit" at the Countess of Chester Hospital.
Letby, who is now 36, was convicted of murdering seven babies and attempting to murder seven others, one of them twice. The inquiry described a system of "dysfunctional management and governance" at the hospital. Letby was sentenced in 2023 to 14 whole life terms, receiving an additional sentence in 2024 after a retrial.
If the babies Letby was convicted of murdering were removed from the hospital's annual mortality figures for the neonatal unit, the numbers would have been three in both 2015 and 2016, figures consistent with previous years. Since July 2016, there has been one death on the unit, in September 2019.
Police were first called into the hospital in 2017. Thirlwall noted that "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." The inquiry found that existing safeguarding guidance was ineffective if concerns were not acted upon. A significant finding was that there is "still no NHS-wide protocol on deliberate harm."
The report detailed Letby's conduct, including ignoring management instructions, shouting at her manager, and falsifying records. In one instance, an infant in her care was found covered in faeces. Colleagues and patients described her as untruthful, "inappropriate," and "callous."
Following an investigation lasting approximately 14 months, police arrested Letby, then 28, on three occasions before charging her with multiple baby murders and attempted murders in November 2020. Her trial commenced in October 2022 and concluded after about 10 months. The jury found her guilty of seven counts of murder and six counts of attempted murder. Verdicts could not be reached on six other counts, and she was found not guilty on two counts of attempted murder. She received a 15th life sentence in 2024 for one of the attempted murder charges.
Thirlwall's report, comprising over 1,100 pages across three volumes, includes 17 recommendations. Among these are proposals for baby monitors to be fitted in cots and incubators on neonatal units. Additionally, access to substances like insulin, which Letby administered to some of the infants she killed, should be controlled through biometric data or CCTV monitoring. The report also calls for the creation of a "suspicion of deliberate harm" policy for managers and mandates that NHS staff be contractually obligated to follow safeguarding policies and guidance.