The chairwoman of Lady Justice Thirlwall’s investigation into the killings carried out by nurse Lucy Letby has determined that the loss of babies at the Countess of Chester Hospital was avoidable if safeguarding measures had been put into practice. She identified a “complete failure to protect babies on the neonatal unit,” with poor management and governance at the core of the collapse.
Letby, now 36, was sentenced to 14 whole-life terms in 2023 after being found guilty of seven murders and seven attempted murders. A second trial in 2024 added another life sentence after a jury reached a verdict on one of the attempted murder counts the original jury had been unable to reach.
The Pattern That Should Have Triggered Action
Of the four deaths recorded across June 2015 and August 2015, three of them — babies A, C and D — happened in quick succession in early June, and were not regarded as a cluster despite matching the full year’s count packed into just two weeks. Baby E’s death in August came as an unanticipated event and was examined at a serious incident panel meeting, where both the medical director and director of nursing were present.
What Thirlwall called “surprising” was that no connection was made by anyone involved to the earlier deaths. By August of that year, the total of four deaths was the highest since 2008, and it was to double by the end of the year.
Dr Thirlwall concluded that safeguarding measures should have been taken had the doctor, identified in the report as Dr ZA, not ignored the insulin test result for baby F in August 2015. Such intervention would have stopped the attacks on babies G and H, J, K, L, M and N, and prevented the deaths of baby I, O and P.
How Delay Cost Babies Their Lives
If all the babies Letby was convicted of murdering were taken out of the yearly count of deaths on the neonatal unit, the mortality numbers would stand at three in 2015 and three in 2016, which roughly matches what had happened before. From July 2016 onward, there has been just one death on the unit, occurring in September 2019.
The deaths of babies O and P could have been avoided, along with the attacks on babies J, K, L, M and N, if safeguarding measures had been put in place by October 2015, following the death of baby I, by removing Letby from the ward.
By February 2016, Dr Ravi Jayaram was required to report what he had observed concerning baby K. Five months later, in May 2016, nobody brought up safeguarding during a meeting with executives — had they done so, the deaths of babies O and P might have been prevented.
Leadership Failed Again And Again
She noted that hospital bosses acted with “high-handed, against all safeguarding principles, and foolhardy.”, a point Thirlwall made when she said they were “repeatedly failed in the duty of candour with parents, investigators and regulators.”.
Medical director Ian Harvey “sought to control the narrative,” presenting the case as he saw it. He made sure that only documents that supported his case were seen, if necessary writing them himself.
When there was a suspicion that a baby had been harmed and others might be at risk, Alison Kelly, director of nursing and head of safeguarding, knew she had to act — but she did not.
The way Tony Chambers ran things when it came to outside experts was domineering, and the presentations he gave to the board were an “exercise in spin.”. His aim all along was to slow down or stop the police inquiry, and he managed to hold that up for nearly a year.
The report was critical of a raft of internal and external reviews commissioned by hospital leadership after concerns were raised about Letby. Director of nursing for urgent care Karen Rees had “lost all judgement” and had a “hostile approach,” Thirlwall found. Unit manager Eirian Powell’s judgement “was affected by the view that Letby was a very good nurse.”
Parents Kept in the Dark
Babies’ parents were placed under “kept in the dark for years” because there was worry that their children might have been harmed on purpose. Thirlwall described the treatment as “reprehensible,” and he noted that hospital officials cited the risk of upsetting the parents as a handy reason for avoiding a police call.
Regarding how doctors were treated, she argued it should “never have been about nurses against doctors… it was about keeping babies safe.”. The doctors were not granted the protection of the Speak Out Safely whistleblowing policy, and senior managers attempted to “manage out”, implying consultants could be reported to the General Medical Council watchdog.
The hospital called in police when 2017 occurred, and Thirlwall went on to say 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.”.
“All the safeguarding guidance in the world makes no difference to the safety of babies if those to whom concerns are expressed do nothing,” she said. She highlighted that there was “still no NHS-wide protocol on deliberate harm.”
What Letby Did
When she disagreed with management instructions, Letby ignored them outright, and she was caught shouting at her manager. The report also found that she falsified records and that an infant under her care was discovered covered in their own faeces. She was repeatedly found to be untruthful in her dealings with friends and colleagues, and patients described her as “callous” and “inappropriate”.
During an investigation that spanned roughly 14 months, Letby was arrested on three separate occasions before being charged with multiple baby murders and attempted murders in November 2020. Her trial took place at Manchester Crown Court, where it ran for about 10 months after beginning in October 2022. She was found guilty of the charges, and she received the life sentences detailed above.
Key Facts Box
- Seven babies murdered
- Seven babies attempted to be murdered
- 14 whole-life sentences handed down in 2023
- Second life sentence added in 2024 after a retrial
- First three deaths in June 2015: babies A, C and D
- Fourth death: baby E, August 2015
- One death since July 2016: September 2019
- Police called in 2017
- Trial began October 2022, lasted about 10 months
Timeline Of Events
| Date | Event |
|---|---|
| June 2015 | Babies A, C and D die |
| August 2015 | Baby E dies |
| August 2015 | Insulin test result for baby F disregarded |
| October 2015 | Death of baby I |
| February 2016 | Dr Ravi Jayaram should have reported baby K |
| May 2016 | No safeguarding raised at exec meeting |
| November 2020 | Charges brought, multiple murders and attempted murders |
| October 2022 | Trial begins at Manchester Crown Court |
The system failed babies because adults failed to act on the warning signs before them, Thirlwall concludes. From the beginning, the pattern of deaths was visible. Again and again, the chance to stop Letby was there. What was missing was the courage to act.
The inquiry has named the failures.
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