Three babies murdered by former neonatal nurse Lucy Letby could have been saved if National Health Service (NHS) managers had alerted police more quickly, a public inquiry has concluded. Lady Justice Thirlwall, who led the investigation into Letby's crimes, stated there was a "complete failure" to protect infants at the Countess of Chester Hospital.
According to the inquiry, managers and senior nurses did not accept the suspicions raised by consultants about Letby. Dysfunctional leadership from senior executives led to a significant delay in involving law enforcement. The report also described the handling of information to the families as "disgraceful" and "reprehensible," noting they were kept in the dark for years about fears that children were being deliberately harmed.
Instead of alerting the police, hospital administrators reportedly prioritized the institution's reputation over the safety of the babies. They commissioned external investigations that failed to identify the cause of the escalating deaths. The report indicated that relationships between the consultants raising concerns and hospital executives deteriorated, with attempts made to sideline the doctors rather than treat them as whistleblowers.
Letby, 36, is currently serving 15 whole-life sentences after being convicted of murdering seven infants and attempting to murder seven others between June 2015 and June 2016. Lady Justice Thirlwall's report suggests that up to three children, including twin brothers known as Baby O and P, and a baby girl identified as Baby I, might have survived had proper safeguarding measures been implemented by hospital bosses.
The inquiry highlighted a disregarded abnormal blood test in August 2015, which indicated Letby had poisoned a twin boy, Baby F, with insulin. This test, which occurred after a point where no further harm should have been permitted, was reportedly overlooked, allowing Letby to continue her actions. She subsequently harmed up to seven more children, at least one of whom suffered brain damage and life-altering injuries, before being removed from the ward in July 2016.
Lady Justice Thirlwall noted that the failure to recognize the significance of the blood test and an incident in February 2016, where a doctor observed Letby "doing nothing" to help a baby girl whose breathing tube she later dislodged, represented missed opportunities. Even the initial unexpected death of Baby A in June 2015 could have triggered police involvement under sudden death protocols if applied in a hospital setting. The judge emphasized that sooner police involvement would likely have occurred had managers acted appropriately.
The 822-page report, which drew on evidence from over 130 witnesses and thousands of documents, cost an estimated £18.5 million. Lady Justice Thirlwall clarified that her report did not re-examine Letby's criminal convictions, which she has unsuccessfully appealed twice. Letby maintains her innocence, and her case is currently under review by the Criminal Cases Review Commission.
The report detailed "dysfunctional management and governance," a gap between hospital leadership and clinicians, and a failure to grasp basic safeguarding principles. It recommended measures such as fitting all neonatal unit cots with baby monitors for remote parental viewing and to act as a deterrent. Strict control over hospital insulin access with CCTV surveillance in fridges was also suggested. By April, all NHS Trusts are required to have board-level monitoring mechanisms for child and baby deaths.
The inquiry criticized senior nurses and managers, including former chief executive Tony Chambers, medical director Ian Harvey, and director of nursing Alison Kelly. The report found that conflicts between doctors and nurses, particularly concerning loyalty to Letby, distracted from infant protection. Alison Kelly, responsible for safeguarding, failed to report the deaths to relevant boards, stating it "never occurred" to her that such fatalities could be a safeguarding issue. Both Kelly and Harvey reportedly struggled to believe a nurse could be responsible, despite lacking experience with premature babies.
The hospital board did not receive reports on the babies' deaths, which the judge deemed a "serious failure of governance." Inspectors from the Care Quality Commission were also criticized for not being provided with data on the spike in deaths during a February 2016 visit.
Concerns about Letby were documented in a review by the head of the neonatal unit, Eirian Powell, and lead clinician Dr. Stephen Brearey, circulated in March 2016. Despite requests for meetings and escalating concerns, hospital executives reportedly ignored or dismissed the review's findings. A May 2016 conversation where Dr. Brearey highlighted Letby's presence during multiple deaths and arrests led to a meeting where consultants' fears were "shouted down." The report noted that even then, suspicion was sufficient for safeguarding steps, but none were taken.
The deaths of the triplet brothers, Baby O and Baby P, in June 2016, served as a "tipping point." Although Dr. Brearey requested Letby be removed from the unit, the executive on duty, Karen Rees, reportedly refused, with the judge dismissing her claims of a relationship between Dr. Brearey and Letby. Letby was allowed to continue working and allegedly attacked another baby, Baby Q, the following day.
Managers subsequently organized a meeting with other staff to devise a plan, which included supervising Letby and commissioning an external review. Lady Justice Thirlwall characterized this approach as a "serious failure by senior managers."
By June 29, 2016, executives agreed that police needed to be called, but this decision was reportedly reversed after a discussion with Chief Executive Tony Chambers. The judge stated that senior managers dismissed the possibility of Letby deliberately harming babies, failing to consider why the doctors hadn't contacted police themselves. Letby was eventually moved to an administrative role after returning from holiday.
The inquiry also found that information was "drip-fed" to reviewers of the deaths, and families were "misled" about the findings. Lady Justice Thirlwall concluded that the failure to call the police at that stage was "impossible to defend."