CHESTER — Lady Justice Kathryn Thirlwall published the final report of the Thirlwall inquiry on Tuesday. The 822-page document concluded that hospital bosses failed to act sooner, a delay that meant three babies might have survived and seven others could have been protected.

Senior nurses effectively dismissed concerns about Lucy Letby, leading to a prolonged delay in calling the police. Clinicians were made the subject of investigation in a grievance process brought by Letby after she was removed from the neonatal unit in July 2016. The inquiry found that parents were kept uninformed for years about concerns that their babies may have been deliberately harmed. Lady Justice Thirlwall described the treatment of parents as "reprehensible."

Lady Justice Thirlwall stated that safeguarding action is required when a staff member is suspected of causing deliberate harm and does not require colleagues to be sure of guilt. The inquiry found that two newborn twins would not have died and five other babies would not have been harmed if Letby had been removed from the neonatal unit sooner. It also found that a third baby who died and two others who suffered unexplained collapses might have been protected if a doctor had detected an earlier insulin poisoning. One infant protected by earlier detection of insulin poisoning, now aged 11, suffered a lifelong brain injury and requires 24-hour care.

The Thirlwall inquiry made 14 recommendations, including installing cameras on every cot in neonatal units. It also recommended round-the-clock CCTV over hospital refrigerators containing insulin. Health Secretary Yvette Cooper promised to set up a hub to track the progress on implementing the inquiry's recommendations. Dr John Gibbs apologized to the families of the victims.

Letby was convicted of murdering seven babies and attempting to murder seven others at the Countess of Chester Hospital between June 2015 and June 2016. She is serving 15 whole-life prison terms but maintains her innocence. The Criminal Cases Review Commission is reviewing evidence submitted by experts on Letby's behalf. Mark McDonald is Letby's barrister.

Barrister Mark McDonald stated the inquiry was based on the 'wrong premise' that Letby is guilty and argued its recommendations may become redundant if her appeal to the Court of Appeal succeeds. Retired Detective Superintendent Stuart Clifton, who investigated Beverley Allitt, stated in January that Letby was the victim of 'the greatest miscarriage of justice of the century'. The neonatal center at the Countess of Chester Hospital has been demolished by a demolition team. The Thirlwall Inquiry cost £18 million.

Timeline

Letby was convicted of murdering seven babies and attempting to murder seven others at the Countess of Chester Hospital between June 2015 and June 2016 on June 30, 2016. Clinicians were made the subject of investigation in a grievance process brought by Letby after she was removed from the neonatal unit in July 2016 on July 1, 2016. The inquiry found that protecting the hospital’s reputation was prized more highly than doctors’ concerns, as police were not contacted until April 2017 on April 1, 2017.

The inquiry conducted its public hearings between September 2024 and March 2025, and published its report and recommendations on 15 September 2026.

What's New

Lady Justice Thirlwall stated that errors were made by nurses, doctors, and managers at the Countess of Chester Hospital. Lady Justice Thirlwall stated there was a "complete failure at all levels to invoke safeguarding procedures at any point." The Thirlwall Inquiry report states that if all the babies whom [Letby] was convicted of murdering were removed from the annual number of deaths in the neonatal unit, the mortality figures would have been three in 2015 and three in 2016 - broadly consistent with previous years.

Why It Matters

The events described span 11 years, from 2015 to 2026. The inquiry report is 822 pages long and represents a comprehensive review of the failures at the Countess of Chester Hospital. The findings highlight systemic issues in healthcare governance and the critical importance of safeguarding procedures in neonatal units.

The recommendations aim to prevent similar failures in the future, with specific measures such as CCTV installation. The ongoing review by the Criminal Cases Review Commission and the statements from legal representatives indicate that the case remains a subject of significant legal and public interest. The demolition of the neonatal center marks a physical end to the location where these events occurred.