Some of Letby's murders could have been stopped - inquiry

British nurse Lucy Letby was able to murder seven newborns because of a "complete failure" to protect babies at the hospital at which she worked, and some of the deaths could have been avoided, the chair of an inquiry has said.

Inquiry chair Kathryn Thirlwall criticised senior staff for not acting sooner, blaming dysfunctional management at the Countess of Chester Hospital in northern England and a basic lack of understanding of safeguarding.

Letby, 36, was convicted in 2023 of murdering seven babies and attempting to murder six others, making her Britain's most prolific serial child killer of modern times.

She was later convicted of another attempted murder charge.

Prosecutors said Letby attacked the newborns by giving them an overdose of insulin, injecting them with air or force-feeding them milk between June 2015 and June 2016, in a case that shocked Britain and drew worldwide attention.

But Letby, who was sentenced to life without parole and maintains she is innocent, has also been the subject of a growing campaign, backed by some medical experts and specialists, which has publicly questioned her convictions.

Ms Thirlwall, who previously criticised "noise" around the case, did not address Letby's guilt or innocence in her report, dealing with the Countess of Chester Hospital's response and whether suspicions should have been raised earlier.

"My focus has been on the questions asked in the (inquiry's) terms of reference, not on the guilt of Lucy Letby or on her convictions," Ms Thirlwall said.

The contents of her report, though, will be pored over by those who assert Letby's innocence and examined by the Criminal Cases Review Commission, an independent body that reviews potential miscarriages of justice and is considering an application from Letby's legal team.

Report criticises failure to act

"Once there was suspicion that Letby may be causing harm deliberately, safeguarding steps should have been taken," Ms Thirlwall said as she delivered her final report.

She added: "No one seems to have thought that safeguarding action is required when a member of staff is suspected of causing deliberate harm. Suspicion is enough."

She made a series of recommendations to improve neonatal services in the state-run National Health Service, calling on the government to tackle the "long-standing underfunding of hospital services for babies and children".

Ms Thirlwall also suggested a series of measures to protect patients, including fitting cots and incubators with cameras, stronger insulin storage safeguards and an NHS protocol for when staff are suspected to have deliberately harmed a patient.

Her report was particularly critical of senior executives and nursing leaders at the Countess of Chester Hospital, saying at least some of Letby's crimes could have been prevented if action was taken sooner.

Three senior hospital managers were arrested last year on suspicion of gross negligence manslaughter and remain under investigation, Cheshire Police said, with one of the three also suspected of perverting the course of justice.

Evidence submitted by the force in support of further charges relating to Letby's time working at the Countess of Chester Hospital and Liverpool Women's Hospital was, however, deemed to be insufficient by prosecutors last year.

Parents of Lucy Letby's victims 'kept in the dark’ about suspicions

The parents of Lucy Letby's victims were kept in the dark about suspicions by the hospital, the inquiry found.

In her report, Ms Thirlwall said families of the babies were not aware of concerns until the nurse was arrested and they were contacted by police in July 2018.

The Thirlwall Inquiry found parents were "kept in the dark for years about what was happening and about the fact that there were concerns that their babies may have been deliberately harmed".

Ms Thirlwall said it was "the wrong call" for the hospital not to keep parents informed about the police investigation.

She said: "Once the police were investigating the circumstances of the deaths of and injuries to their babies, the parents had the right to know about it.

"They should have been informed."

In July 2016, the mother of baby C found out about a review by the Royal College of Paediatrics and and Child Health (RCPCH) which followed an increase in deaths on the neonatal unit after a friend alerted her to an article in the local newspaper, the inquiry heard.

Hospital staff told her it was a "formality" because of a small increase in the number of deaths, she said.

In her report, Ms Thirlwall said: "This was not a question of balance, Mother C was being misled.

"It was not a question of not getting the communication right; it was about not being straight with parents who had the right to know what was going on."

The inquiry heard parents felt the hospital was more concerned with its reputation than with their children.

The mother of baby I said: "They shouldn’t have been concentrating on saving their own skins and jobs and reputations.

"Babies died because someone in an office being paid hundreds of thousands of pounds didn’t want the hospital to look bad if they shut."

Ms Thirlwall said: "No one could disagree with any of these observations."

The report found the lack of consideration shown to parents at that time was "reprehensible".

In his evidence to the inquiry, medical director Ian Harvey accepted that communication with families about a report carried out by consultant neonatologist Dr Jane Hawdon was "both crass and inappropriate".

Ms Thirlwall said: "This was a complete apology for the abject failure of communication with the parents in respect of Dr Hawdon’s report."

Additional reporting PA