Thirlwall Inquiry Finds 'Complete Failure' at Hospital Let Lucy Letby Keep Attacking Babies for a Year

Lady Justice Kathryn Thirlwall published her inquiry's findings today at Liverpool Town Hall, roughly two years after the probe launched in September 2024 following Lucy Letby's convictions for murdering seven newborns and attempting to murder seven others at Countess of Chester Hospital.

The verdict from more than 130 witnesses and 400 statements gathered over six months: hospital leadership failed these babies completely.

"There was a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital," Thirlwall wrote, according to the BBC. "My report describes dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals of safeguarding."

Three Babies, Seven Others

Thirlwall concluded three babies might have survived and seven others could have been spared harm if hospital bosses had acted on doctors' concerns, according to the Guardian. Two newborn twins would not have died and five others would not have been harmed had Letby been pulled from the unit sooner. A third baby, a two-month-old girl, and two others who suffered unexplained collapses might have been protected if a doctor had caught an earlier insulin poisoning. One of those infants, now 11 years old, suffered a lifelong brain injury and requires round-the-clock care.

The inquiry traced a specific missed turning point to August 2015, when a doctor identified in the report only as Dr ZA disregarded an abnormal insulin test result for Baby F. The BBC reported that if that result had triggered safeguarding action, it would have prevented the attacks on Babies G, H, J, K, L, M and N and the deaths of Babies I, O and P. A May 2016 meeting where senior managers discussed the unusual mortality spike and one nurse's presence at every incident never raised safeguarding as an issue. "This should not have happened, and babies O and P should not have died," Thirlwall wrote, according to the Journal.ie.

Cover-Up, Not Just Incompetence

Thirlwall's report goes further than sloppy management. She found senior nurses never accepted that consultants' concerns about Letby were valid and that there was a "prolonged delay" in calling police, according to the Guardian. Medical Director Ian Harvey failed to disclose the full nature of concerns about Letby to outside reviewers, which meant those reviews never properly assessed the possibility of deliberate harm, ITV reported. Had Harvey "been frank," the report said, police would have been called much sooner.

When clinicians pushed back, the hospital turned on them. Letby filed a grievance against the consultants who raised alarms after she was finally moved off the neonatal unit in July 2016, a process Thirlwall called "deplorable," according to the Guardian. Cheshire Constabulary wasn't invited to investigate until May 2017. Letby remained employed at the hospital for more than a year after that before her arrest.

Parents were kept in the dark the entire time about suspicions their babies might have been deliberately harmed. Thirlwall called that treatment "reprehensible" and said executives used the risk of upsetting families as a convenient excuse to avoid calling police, CBS News reported.

14 Fixes, One Deadline

The report makes 14 recommendations, including fitting baby monitors in every cot and incubator on neonatal units so parents can watch remotely, and installing CCTV cameras trained on insulin storage fridges. Thirlwall directed NHS England to publish a roadmap for implementing the monitor recommendation by March 31 next year, the Guardian reported.

Coverage of the report's physical scope diverged: the BBC described it as running more than 1,100 pages across three volumes, while ITV described a four-volume report totaling more than 800 pages. Both outlets agree on the substance of the findings even if the page count differs.

What the Inquiry Didn't Touch

Thirlwall's inquiry proceeded entirely on the basis that Letby's convictions stand, and it did not examine her guilt, her motives, or the evidence against her. That's a deliberate limitation, not an oversight.

Letby, 36, is serving 15 life terms with no possibility of release, one of only four women in the UK to receive that sentence. She was convicted in 2023 of seven murders and six attempted murders, with a retried hung count adding an additional attempted-murder conviction in 2024. She has maintained her innocence throughout, and her defense team, backed by a panel of scientists who say the medical evidence doesn't support deliberate harm, is pressing the Criminal Cases Review Commission to send her case back to the Court of Appeal. CCRC chair Vera Baird told the BBC the watchdog is actively reviewing the case to determine whether there's a "real possibility" the convictions won't be upheld. Letby's attorney, Mark McDonald, unsuccessfully tried to halt the Thirlwall inquiry altogether, arguing it risked reaching conclusions that could later be undermined if her convictions are overturned.

That appeal fight remains unresolved. If the CCRC refers the case back to appellate judges and any conviction is overturned, Thirlwall's findings about a hospital cover-up would stand on their own, but the causal story linking specific deaths to a single perpetrator would need to be revisited entirely.