Health Secretary Yvette Cooper says plans are under way to install “cot cams” in neonatal units after a damning report found hospital staff could have prevented three of killer nurse Lucy Letby’s murders.
The Thirlwall Inquiry’s final report said Letby should have been removed from the neonatal unit at Countess of Chester Hospital before Babies O and P came to harm, while if doctors had acted on abnormal insulin tests relating to Baby F, whom Letby attempted to murder, then Baby I may have also been saved.
The report says hospital executives prioritised “prevention of reputational damage” over the string of neonatal deaths and found there had been a "complete failure" to protect children.
Lady Justice Thirlwall’s report examines events that led to the former nurse’s convictions for murdering seven infants and attempting to murder seven others between June 2015 and June 2016. Letby, 36, is serving 15 whole-life orders for the crimes.
The report sets out a number of safeguarding recommendations, including the introduction of baby monitors in every cot on neonatal wards. Lawyers representing several families affected said it was vital changes were implemented.
The inquiry does not look at whether Letby was guilty, but how concerns about the nurse from other staff were handled and whether her actions could have been prevented.
Key Points
- Government to introduce video cameras in neonatal units
- 'Complete failure' to protect babies at Chester hospital, report finds
- Health secretary says government ‘profoundly sorry’
- Parents of Lucy Letby’s victims ‘kept in the dark’ about suspicions
- Thirwall Inquiry report - what does it mean for Letby's defence
- 'Last thing we want is sensational press' ex-chief executive said months before police called in
Government to introduce video cameras in neonatal units
15:04 , Jane DaltonHealth secretary Yvette Cooper says she has asked officials to develop plans to install “cot cams” in neonatal units.
She told the Commons: “On safety and reassurance for parents, Lady Justice Thirlwall recommends the introduction of video baby monitors for neonatal units. I agree.
“I have asked my officials to urgently develop plans for cot cams, which can also help parents feel better connected to their babies when they aren’t able to be with them in person.”
The Government takes the recommendations from the Thirlwall Inquiry “very seriously”, Ms Cooper added.
'Last thing we want is sensational press', ex-chief executive told Letby months before police called in
15:01 , Alex RossThere is more criticism for former chief executive Tony Chambers over a meeting he held along with senior staff with Letby and her parents in February 2017.
Notes from the meeting showed that Mr Chambers told Letby he supported her transition back to the neo-natal ward, which Lady Justice Thirlwall flagged in her report of the inquiry as "untrue".
He also told her: "Don't worry, we have got your back".
Such comments were described as "clumsy language" to avoid any possible escalation by Mr Chambers when giving evidence at the inquiry.
Lady Thirlwall described it as "misconceived and dishonest".
Mr Chambers also said at the meeting, according to its minutes, "last thing we want is sensational press", before saying to Letby: "We don't want the story to be about you; that would be horrific."
Lady Thirlwall said fears of a story in the press were clearly a matter of concern to Mr Chambers.
Minutes from the meeting also recorded Sue Hodkinson, former director of HR, responding to a question from Letby, asking "what if I leave?".
She said: “There will be nothing on your record; it will not affect your reference or any other matters."
Police were formally called in to investigate baby deaths in May 2017, before Letby was arrested the following year.
Ministers to set up NHS 'recommendation hub' to ensure advice implemented
14:56 , Jane DaltonHealth secretary Yvette Cooper has promised to set up a new recommendation hub to track the implementation of Lady Justice Thirlwall’s recommendations in her report.
She acknowledged Lady Thirlwall’s concerns surrounding past inquiry recommendations not being implemented.
She told MPs: “My department is setting up a recommendation hub to properly track our implementation progress internally, not just for this inquiry, but for others, right across the NHS.
“But we will work with the Cabinet Office now on improvements in this area to respond to this inquiry.”
Cooper says government ‘profoundly sorry’ for failures
14:52 , Jane DaltonThe government has issued an apology for the failures set out in Lady Justice Thirlwall’s report prompted by Lucy Letby’s crimes.
Health secretary Yvette Cooper said the government was “profoundly sorry” for the failures, harm and distress caused.
“Let me address the issues for the families and the parents directly, because the suffering endured by these babies and their families is impossible to comprehend,” she told MPs.
“On behalf of the government and the health service, I am profoundly sorry for the failures set out so clearly in this report, for the harm, distress and unthinkable loss for their families, and for the failures to keep their babies safe.
“Our responsibility now is to act.”
Shocking failures in most basic duty of candour, health secretary says
14:47 , Athena StavrouHealth secretary Yvette Cooper has acknowledged Lady Thirlwall’s “devastating conclusion” that some babies could have been saved had action been taken earlier.
She laid out “shocking failures” in the hospital after concerns about the possibility of deliberate harm were raised by clinicians.
“But then repeated failures of organisations and individuals to act, shocking failures to put the safety of babies first, shocking failures on safeguarding, failures in governance, in regulation, failures in the most basic duty of candour, failures in professional curiosity, and repeated failure to refer concerns to the police, which the inquiry is clear should have been done at a much earlier stage,” she said.
Hospital bosses stay silent
14:44 , Jane DaltonFour former senior managers at the Countess of Chester Hospital identified in the report have refused to comment since publication of the inquiry report.
Sue Hodkinson, Alison Kelly, Ian Harvey and Tony Chambers said: ”We are carefully reviewing the Thirlwall report and its recommendations.
“Given that there are a number of investigations under way, and that the work of the Criminal Cases Review Commission has not yet completed, it would be inappropriate for us to offer any further comment at this time.
“Our thoughts remain with the families affected by the tragic events that took place at the Countess of Chester Hospital.”
At the beginning of the inquiry, held at Liverpool Town Hall, three of them issued an apology for not alerting Cheshire Police sooner.
The hospital bosses sorry for ‘significant delay’ in alerting Lucy Letby to police
Hospital former chief executive told Letby's parents 'we didn't believe' concerns
14:40 , Jane DaltonLady Justice Thirwall has again criticised in her report the evidence provided by former chief executive Tony Chambers.
In notes of a meeting held with Letby's parents in December 2016, Mr Chambers was reported to have told them: "We are within our rights to phone the police but we didn’t believe it."
This was more than six months before the hospital called in Cheshire Police over their concerns on Letby.
When asked if he had said that, Mr Chambers had told the inquiry he had instead said he wanted to try to understand the causes behind the unexplained increase in deaths.
In her report published today, Lady Justice Thirwall said: "This convoluted sentence was his attempt to explain away the fact that he had said: “[W]e didn’t believe it.”
"I am satisfied that he did say it, not least because that was what he wanted Letby and her parents to believe."
Lady Thirwall also said that the meeting, where Letby's father became angry, was "very badly handled", and it was Mr Chambers’ responsibility.
The hospital bosses sorry for ‘significant delay’ in alerting police
14:30 , Jane DaltonThe hospital bosses sorry for ‘significant delay’ in alerting Lucy Letby to police
Bosses noted suspicions of deliberate harm a year before alerting police
14:20 , Rebecca ThomasBosses at the Countess of Chester Hospital did not alert police to Letby until May 2017.
In a chapter examining executives' responses to a doctor’s early concerns, the inquiry found evidence that executives Alison Kelly and Ian Harvey were aware of suspicions that deliberate harm to babies was a “possibility” in May 2016.
Citing oral evidence from Ms Kelly to the inquiry, the report said that at a meeting on 11 May 2016, Dr Stephen Breary had raised concerns that the increase in neonatal mortality may be attributable to Letby that “although he did not explicitly say that he had concerns about deliberate harm”.
“Ms Kelly accepted that concerns about Letby’s involvement in the deaths could only mean one of two things: incompetence or deliberate harm.
“She acknowledged that she knew “from his [Dr Brearey’s] perspective there was a possibility that that was deliberate”. This is important as it is the first admission from a member of the Executive Team that they were aware that deliberate harm was a possibility. If it was plain to Ms Kelly, it was plain to Mr Harvey. This was in May 2016.”
It said the subsequent agreement to “‘wait and see’ – or ‘monitor and alert’ was a serious mistake.”
“Whilst ‘wait and see’ may be a well-recognised approach in clinical practice, it could never be appropriate when what is being waited for is, at a minimum, harm to a baby.”
Watchdog failed to investigate enough, boss admits
14:16 , Jane DaltonThe Care Quality Commission regulator “did not take an approach which was sufficiently investigative and inquiring” when it inspected the Countess of Chester Hospital at the centre of the inquiry, said Dr Toli Onon, CQC’s chief inspector of hospitals.
A team from the CQC carried out a routine inspection of the hospital on a four-day visit in February 2016 with unannounced visits in the weeks that followed.
CQC inspectors not told of concerns over deaths at Letby hospital, inquiry hears
Letby lied and ignored bosses' orders, inquiry says
14:10 , Jane DaltonLucy Letby ignored instructions from managers when she disliked them, and shouted at her manager, the inquiry has found.
In dealings with colleagues and friends, the nurse repeatedly was untruthful, Lady Justice Thirlwall said, and Letby also faked records.
Patients noted she had an “inappropriate and callous” nature.
One baby under her care was found covered in their own faeces.
Boyfriend put helping Letby above duty, inquiry says
14:00 , Jane DaltonA doctor “boyfriend” of Lucy Letby blurred boundaries and put his desire to help her above his duties to his patients, the inquiry found.
Consultant paediatrician Mark Deakin, 53, who died earlier this year, exchanged more than 1,300 Facebook messages with Letby between June and September 2016, the Thirlwall Inquiry heard.
In her report, Lady Justice Thirlwall said the doctor had contacted Letby after a mortality review for babies O and P in July 2016.
He told her she needed to “keep it to herself” but said: “If you have any doubt about how good you are at your job, stop now, documentation was perfect.”
He also forwarded an email to her from Dr Stephen Brearey in which he was told there was likely to be an inquest.
When asked at the inquiry why he did that, he said he was trying to reassure and “give her some insight” but accepted, in hindsight, it was an error.
Lady Justice Thirlwall said: “I agree with him. It is another example of the blurring of boundaries.
“Here, between his duties to his patients, and his desire to help and support a young nurse who had, as he did not realise, many people supporting her. He put her first.”
The report says the doctor’s support for Letby continued well into 2017.
Why was action not taken sooner over Letby concerns?
13:50 , Nicole Wootton-CaneThe Independent’s health editor Rebecca Thomas reports:
In a chapter examining the responses of concerns raised about Letby to managers from June 2015 to June 2016, the inquiry asks: “Why was action not taken sooner?”.
It found senior nurse managers found it “unthinkable” that Letby might be harming babies, describing one senior manager as “steadfast” in her support.
Speaking of board members, Lady Thirlwall found from the outset they had “dismissed” the idea that the nurse was deliberately harming babies.
“They did not believe it,” the report said, however concluded, “whether the senior managers believed Letby was harming babies or not was irrelevant to their duties and responsibilities to take safeguarding action.”
Addressing why consultants had their concerns, the inquiry said: “I have no doubt that the consultants’ concerns were held in good faith and were based on their clinical judgement.
“It is clear that they did not know what Letby was doing to harm babies (the two cases of insulin poisoning having been missed).
“This undermined their confidence and contributed to Dr Brearey being shouted down by the forthright and determined views of the senior nurses at the meeting on 11 May 2016."
Letby’s lawyer claims cot cameras would have prevented her conviction
13:40 , Nicole Wootton-CaneThe Independent’s crime correspondent Amy-Clare Martin reports:
Mark McDonald, the barrister leading Lucy Letby’s efforts to overturn her convictions, has said he supports the idea of CCTV in neonatal units and cameras in cots.
The barrister claims the measures recommended by Lady Justice Thirlwall would have “significantly impacted the outcome at trial and we would not be where we are today with an innocent woman in prison for crimes she did not commit”.
In a statement following the publication of the Thirlwall report, he also insisted the inquiry had proceeded on the wrong premise.
"This inquiry has proceeded on the wrong premise, and it follows that this has inevitably affected the report as a whole,” he said.
“Errors made at trial have in important respects been repeated in the inquiry’s conclusions, and the alternative narrative identified by nearly 30 internationally renowned experts has not been properly considered.”
He also said it was “particularly regrettable” that Ms Letby’s application to be represented at the inquiry was rejected which meant it did not hear an “alternative account”.
The Criminal Cases Review Commission is examining an application by Ms Letby for her case to be sent to the Court of Appeal.
Watch: Lucy Letby inquiry report recommends fitting baby monitors in all cots and incubators in neonatal units
13:25 , Nicole Wootton-CaneThirlwall calls for 'energetic and determined' approach to implementing recommendations
13:15 , Nicole Wootton-CaneLady Justice Thirlwall said work done by the inquiry showed that a “very high number of recommendations” had been accepted by government but not yet implemented.
She said: “If my recommendations are going to be implemented in a timely fashion so that the safety of babies and others in hospital is secured there must be an energetic and determined approach to implementation.”
At the end of her statement at Liverpool Town Hall, she thanked parents of Letby’s victims for contributing so “generously and thoughtfully” to the inquiry.
She said: “They have borne this exercise with dignity and fortitude.
“It is my hope that their work, their evidence, the recommendations of the inquiry which draw on the evidence of many contributors will mean that others do not have to live through experiences like theirs.”
A ‘dysfunctional’ NHS culture that failed to protect babies
13:10 , Nicole Wootton-CaneThe Independent’s health editor Rebecca Thomas reports:
The Thirlwall Inquiry report has laid bare the NHS’ failure to protect babies from harm, concluding that some have been saved from death and harm at the hands of Lucy Letby if safeguarding action had been taken earlier.
Spanning more than 800 pages, the report’s chair Lady Thirlwall describes how a dysfunctional management culture at the Countess of Chester Hospital allowed this to happen.
It describes how senior managers were concerned for the reputation of the hospital, and that this contributed to a long delay between concerns being raised about Letby and contacting the police in May 2017.
The report is another in a long line of examples revealing how the NHS’ culture and approach to reputation management has contributed to the harm and death of patients.
'Regrettable' Letby could not take part in inquiry, nurse's lawyer says
13:05 , Nicole Wootton-CaneLucy Letby’s barrister said it is “particularly regrettable” that his client could not take part in the inquiry.
In a statement, Mark McDonald said: “This inquiry has proceeded on the wrong premise, and it follows that this has inevitably affected the report as a whole. Errors made at trial have in important respects been repeated in the inquiry’s conclusions, and the alternative narrative identified by nearly 30 internationally renowned experts has not been properly considered.
“I do however wholeheartedly agree with the introduction of CCTV in all neonatal units and cots – this would have significantly impacted the outcome at trial and we would not be where we are today with an innocent woman in prison for crimes she did not commit.
“It is particularly regrettable that Lucy’s application to participate in the Inquiry was rejected. Had she been represented, the inquiry would have been able to hear an alternative account – one that said that insulin results were unreliable, one that said the deaths did not stop when Lucy left the unit and one which, in the view of international experts, provides a fundamentally different and more accurate understanding of what happened.”
Former chief executive wanted to 'punish' employees for persisting with concerns over Letby
13:02 , Nicole Wootton-CaneThe Independent’s senior reporter Alex Ross reports:
In what Lady Justice Thirlwall described as "one of the most revealing documents in the inquiry", the report includes a note taken by former HR director Sue Hodkinson of a meeting with former chief executive Tony Chambers which, Lady Thirwall said, set out an "aggressive plan to get rid" of two consultants who had pushed their concerns over Lucy Letby.
The note, taken after Mr Chambers had spoken to police in May 2017, was put to him during the inquiry, but he said he did not recollect the meeting with Ms Hodkinson and that it was really on patient safety.
In her report, Lady Thirwall said it was a "wordy and untruthful explanation". She added: "His obvious intention was to punish the consultants for persisting with their concerns."
'This cannot be allowed to happen again,' families lawyer says
13:00 , Nicole Wootton-CaneRichard Scorer, head of abuse law and public Inquiries at Slater and Gordon, who acts for three families said the events surrounding Letby’s crimes “cannot be allowed to happen again”.
“The families I represent were looking for a clear analysis of what went wrong and strong recommendations to prevent this happening again,” he said.
“The report delivers both. Lady Thirlwall is clear that the police should have been informed in August 2015, not 18 months later, and that hospital managers misled the families and the trust failed in its duty of candour.
“My clients welcome the recommendations around CCTV, access to insulin, strengthening of the duty of candour to include hospital managers and barring of managers guilty of incompetence and misconduct.
“The challenge now is to ensure that recommendations are implemented without delay. Far too often public inquiry recommendations are left to gather dust.
“This cannot be allowed to happen again.”
‘Foolhardy’ behaviour of bosses meant babies not protected – Thirlwall inquiry
12:56 , Nicole Wootton-CaneThe “foolhardy” behaviour of hospital bosses and the divide between nurses and doctors led to the “complete failure” to protect babies murdered by killer nurse Lucy Letby, an inquiry has concluded.
The final Thirlwall Inquiry report went into detail about “dysfunctional management” and criticised executives at the Countess of Chester Hospital for being “high handed” in their handling of infant deaths.
Inquiry chairwoman Lady Justice Thirlwall said in her report that bosses “ignored… patient safety” after concerns were raised about Letby potentially harming and killing babies because they “did not believe the concerns were well founded”.
Following the publication of the report, the senior judge said: “My report describes dysfunctional management and governance; a gulf between hospital leadership and clinicians; and failure to understand the fundamentals of safeguarding.
“There was a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital.
“This was because 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.”
Watch: 'Complete failure' to protect babies at killer nurse's hospital, report finds
12:53 , Nicole Wootton-CaneLack of consideration given to parents 'reprehensible,' Thirlwall says
12:47 , Nicole Wootton-CaneThe 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.”
Lady Justice 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”.
Report not an investigation into Letby's guilt, Thirlwall says
12:45 , Nicole Wootton-CaneLady Justice Thirlwall said her report was not an investigation into the criminal convictions or guilt of Letby.
She said: “It is not for me to second guess or to cut across the work of the Criminal Cases Review Commission which is working on Letby’s application for her case to be referred back to the Court of Appeal.”
She said the families of Lucy Letby’s victims must not be “collateral damage” in the public argument about whether or not the nurse is guilty.
She said: “Everyone commenting on the events at the Countess should remind themselves that these are all real people who have suffered grievously and continue to suffer as a result of the unexpected collapses and/or deaths of their babies and all that has followed in the 10 or 11 years since then.
“Their dignity and courage should be respected by everyone.”
She added: “The anger some parents feel at the way they were treated by the Countess was palpable.
“They were kept in the dark for years about what was happening, about the fact that there were concerns that their babies may have been deliberately harmed.”
At least two babies should not have died, Thirlwall says
12:44 , Nicole Wootton-CaneLady Justice Thirlwall said she had considered if any of the babies’ collapses and deaths could have been prevented.
She said if insulin results relating to baby F had been acted upon at the time, contacting the police would have been unavoidable.
“After the death of Baby I suspicions became clearer,” she said. “If safeguarding action had been taken, Letby should have been moved from the neonatal unit at this point. This did not happen.
“The collapses and deaths continued. At an important meeting in May 2016 safeguarding was not considered, and Letby remained on the ward. This should not have happened, and babies O and P should not have died.”
Inquiry finds 'prolonged delay' by senior managers in calling police over Letby suspicions
12:42 , Nicole Wootton-CaneHospital bosses opted to carry out a number of reviews into the increased mortality in 2015 and 2016, and did not invite Cheshire Constabulary to investigate until May 2017, as Letby remained on site until her arrest more than a year later.
The Thirlwall report found that senior nurses never accepted that the consultants’ concerns were, or might be, justified, and that there was a prolonged delay by senior managers in calling the police.
It ruled that successive internal and external reviews commissioned by hospital leadership after concerns were raised about Letby did not address whether deliberate harm was being caused or not.
Baby monitors and CCTV cameras – Thirlwall Inquiry issues recommendations
12:41 , Nicole Wootton-CaneA total of 14 recommendations have been made in the Thirlwall Inquiry report – including the fitting of baby monitors in all cots and incubators in neonatal units and CCTV cameras focused on insulin storage fridges.
The recommendations follow the conclusions made by inquiry chairwoman Lady Justice Thirlwall, who said the collapse and deaths of some babies could have been avoided if safeguarding practices had been followed.
She said baby monitors would ensure parents could observe their babies “remotely at any time” – adding that NHS England should “set out a road map” for how it could be implemented by 31 March next year.
The senior judge said the cost of the implementation should be “centrally managed and ring-fenced” so it could be rolled out “at speed”.
The inquiry’s chairwoman also said digital devices should be used to “restrict access of insulin to authorised people”, as well as recording access to insulin units.
She said until the devices had been rolled out, which she said must happen by March 31 next year, NHS trusts should “install CCTV cameras focused on storage fridges, cupboards or units”, with recordings kept for at least 28 days.
Trusts should also be able to demonstrate that proposed moves of senior managers to other trusts are not based on a “lack of capability or misconduct”, the report said.
Parents of Lucy Letby’s victims ‘kept in the dark’ about suspicions
12:39 , Nicole Wootton-CaneThe parents of Lucy Letby’s victims were kept in the dark about suspicions by the hospital, an inquiry has found.
In her report, published on Tuesday, Lady Justice 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.
Letby, 36, from Hereford, was convicted of murdering seven babies and attempting to murder seven others at the Countess of Chester Hospital in 2015 and 2016.
The Thirlwall Inquiry, set up to examine how Letby was able to carry out her crimes, 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”.
Lady Justice 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.”
BREAKING: 'Complete failure' to protect babies at Chester hospital, report finds
12:35 , Nicole Wootton-CanePublishing her final report, Lady Justice Thirlwall said there was a “complete failure” to protect babies on the neonatal unit at the Countess of Chester Hospital where Lucy Letby worked.
She said her report into how Letby was able to carry out her crimes described “dysfunctional management and governance; a gulf between hospital leadership and clinicians and failure to understand the fundamentals of safeguarding”.
Speaking at Liverpool Town Hall as her report was published, she said: “There was also complete failure at all levels to invoke safeguarding procedures at any point.
“Looking for clinical or other explanations for deaths and collapses was not wrong, but once there was suspicion that Letby may be causing harm deliberately safeguarding steps should have been taken.
“She should have been removed from the ward as a neutral act and matters could have been investigated without risk to babies.”
Live: Lucy Letby inquiry report into crimes of killer nurse published
12:20 , Nicole Wootton-CaneWill the Thirlwall Inquiry change the NHS’ cover-up culture?
12:15 , Nicole Wootton-CaneThe Independent’s health editor Rebecca Thomas reports:
The Thirlwall inquiry will not be the first to lay bare systemic widespread problems with the NHS’ culture; it comes after years of pubic inquiries and independent reports following healthcare scandals.
In recent years, reports from the Infected Blood inquiry and the Ockenden maternity inquiries have all highlighted how problematic, cover-up cultures persist within the NHS.
The Thirlwall report is set to address whether recommendations to address culture and governance issues made by previous inquiries into the NHS have been implemented into wider NHS practice and to what effect? However its analysis so far suggests little progress has been made after major inquiries.
In 2024, the Thirwall inquiry published an analysis was published into the progress made by the NHS and government after some of the most high-profile health scandals in the UK, it found across 30 inquiries dating back to 1967, just 302 out of more than 1,400 key recommendations had been adopted.
It found the NHS and government have failed to implement a single recommendation from a key Jimmy Savile inquiry – almost 10 years after plans to prevent future sex abuse of patients in hospitals were put forward.
NHS managers will face being disbarred from roles
12:10 , Nicole Wootton-CaneThe Independent’s health editor Rebecca Thomas reports:
The Thirwall Inquiry was tasked with examining responses to concerns raised about Lucy Letby from those with management responsibilities within The Countess of Chester NHS Trust.
The publication of the final report and recommendations comes after the government has already committed to introducing a new statutory barring system for senior NHS managers in England.
Announcing the proposals in July 2025 the government said: “The Infected Blood Inquiry showed the devastating impacts a lack of senior leadership accountability can have and emphasised the need for candour to apply across the NHS, regardless of position, while the ongoing Thirlwall Inquiry into events at the Countess of Chester hospital continues to highlight similar concerns.”
The government has promised to provide funding from January 2027 to begin initial work on the new system in early 2027. However, the timeline for introduction of the new system will depend on legislative changes.
Under the proposals, the Health and Care Professions Council (HCPC) will be provided with statutory powers to disbar NHS leaders in senior roles who have committed serious misconduct from holding these roles in future.
The new system will apply to NHS board-level directors and their direct reports and DSHC and arm’s length body board-level directors. It will cover those found to have committed serious misconduct, including acts designed to suppress whistleblowing, will be barred from holding senior NHS positions in the future.
Lucy Letby: Timeline of killer nurse’s attacks on babies as inquiry report due to be published
12:00 , Nicole Wootton-CaneThe long-anticipated findings of a public inquiry into how Lucy Letby was able to murder seven babies at a hospital neonatal unit will be published on Tuesday.
Two years after the evidence was heard in Liverpool, Lady Justice Thirlwall will publish her report into the actions of the NHS and other institutions at the time Letby carried out her crimes at the Countess of Chester Hospital in 2015 and 2016.
The inquiry’s key objectives are to seek answers for the victims’ families and ensure lessons are learned.
You can read a timeline of events below:
Timeline of Letby’s attacks on babies as inquiry report due to be published
What is the ‘medical evidence’ against Lucy Letby’s convictions - and can she still re-appeal?
11:50 , Nicole Wootton-CaneA panel of experts claimed that Lucy Letby did not commit murder after its chairman presented “significant new medical evidence” on her court case.
Evidence used to convict the killer nurse was newly challenged by Canadian professor Dr Shoo Lee who convened a panel of experts in London for a press conference last year.
Following a review by the 14 experts, he claimed there was no medical evidence to support the convictions and suggested the deaths and injuries were caused by natural causes or "bad medical care".
You can read more about the claims below:
Lucy Letby: What is the ‘medical evidence’ experts say challenges her conviction?
Lucy Letby’s lawyer insists case has not been undermined after experts quit
11:30 , Nicole Wootton-CaneLucy Letby’s lawyer has insisted her case has not been undermined after two experts quit her defence team, saying some of its arguments have “unresolvable problems”.
The former nurse, who maintains her innocence, is serving 15 whole-life terms for the murders of seven babies and the attempted murders of seven others while working on the neonatal unit at the Countess of Chester hospital.
Engineering expert Helen Shannon and bioengineering professor Geoff Chase withdrew from the team on Monday.
The Criminal Cases Review Commission (CCRC), which investigates potential miscarriages of justice, is considering evidence presented on her behalf by an international panel of medics.
The group argued the babies died or collapsed as a result of poor medical care and natural causes.
Asked by BBC Newsnight whether their withdrawal undermined Letby’s case, lawyer Mark McDonald said he “fundamentally” disagreed.
“They don’t know what I put into the CCRC because I haven’t told them. So how on earth could they make that conclusion?” he said. “But really, it comes back to this. Both sets of experts say that Lucy Letby is innocent.
“One set of experts remains in the CCRC. One set of experts have withdrawn. But they both are of the same position that whatever happened at the trial, what took place at the trial, was wrong, that the jury was misled.”
Harmed families say Thirlwall recommendations must be implemented
11:18 , Nicole Wootton-CaneThe Independent’s health editor Rebecca Thomas reports:
Lawyers representing several families say it’s vital the recommendations are implemented by the government.
Tamlin Bolton, the Irwin Mitchell lawyer representing several families, said: “While no system can guarantee the prevention of criminal acts by a determined individual, patients, families and clinicians are entitled to expect that their concerns will be listened to and that those concerns will be investigated properly and acted upon.
“The key questions are whether the systems, culture and governance within our NHS were sufficiently robust to identify risks and respond to them appropriately and where, in this instance, those systems have failed.
“With the families, we will consider Lady Justice Thirlwall's findings carefully, but whatever the detail of the report, it is vital that lessons are learned and any recommendations are implemented by the UK government so that confidence in patient safety is strengthened.”
Thirwall Inquiry report - what does it mean for Letby's defence
11:10 , Nicole Wootton-CaneThe Independent’s senior reporter Alex Ross writes:
At the outset of her inquiry, Lady Justice Thirwall made clear that its aim was not to review Lucy Letby's conviction, but to look at the conduct of hospital management and the effectiveness of governance to keep babies safe.
It was held on the basis of Letby being guilty of the seven murders and seven attempted murders.
The findings, published today, will likely be critical of some of the actions of senior bosses, most of whom no longer working at the Countess of Chester hospital.
Letby's lawyer Mark McDonald will be taking note of the report, but his main focus remains on the Criminal Cases Review Commission (CCRC), which is looking at Letby's convictions following an application the case gets referred back to the appeal courts.
Dame Vera Baird, who is chair of the CCRC, has said she will "be looking at the [Thirwall] report with interest to assess whether it has any bearing on our review of the case.”
Meanwhile, Mr McDonald has said Letby is completely focussed on proving her innocence as she and her team wait on the CCRC's decision. No date has yet been signalled when this will come.
Whole-life orders: The prisoners who will die in jail
10:50 , Nicole Wootton-CaneSerial child killer Lucy Letby will die in jail after she was handed 15 whole life orders for the murders of seven babies and the attempted murders of seven others.
A whole life order means she will not be eligible for release unless there are exceptional compassionate grounds to warrant it.
You can read more about who else has been handed a whole life order below:
Whole-life orders: The prisoners who will die in jail
Watch: Lucy Letby: Timeline of nurse who murdered seven babies
10:30 , Nicole Wootton-CaneWhat did the Thirlwall Inquiry examine?
10:10 , Nicole Wootton-CaneThe Thirlwall Inquiry report will be published at 12:30pm on Tuesday, examining how killer nurse Lucy Letby was able to murder seven babies and attempt to murder seven others.
The inquiry set out its “terms of reference”, describing the scope of the inquiry. These include:
• The experiences of the Countess of Chester Hospital and other relevant NHS services, and of all the parents of the babies named in the indictment
• The conduct of those working at the Countess of Chester Hospital, including the board, managers, doctors, nurses and midwives with regard to the actions of Letby
• Whether suspicions should have been raised earlier, whether Letby should have been suspended earlier and whether the police and other external bodies should have been informed sooner of suspicions about her
• The responses to concerns raised about Letby from those with management responsibilities within the trust
• Whether the trust’s culture, management and governance structures and processes contributed to the failure to protect babies from Letby
• The effectiveness of NHS management and governance structures and processes, external scrutiny and professional regulation in keeping babies in hospital safe and well looked after, whether changes are necessary and, if so, what they should be, including how accountability of senior managers should be strengthened
Letby 'completely focussed on proving her innocence', her lawyer tells The Independent
09:48 , Nicole Wootton-CaneThe Independent’s senior reporter Alex Ross writes:
As we await the publication of the Thirwall Inquiry report at 12.30pm, we have spoken to one of those who will be paying close interest to its findings.
Mark McDonald, Lucy Letby's lawyer who has applied to the Criminal Cases Review Commission (CCRC) for her convictions to be reviewed, had asked for the inquiry to be paused for the outcome of the CCRC's decision.
Asked what the public can take from today's report, he told The Independent: "I have not had sight of the report, but have followed the Inquiry and can be clear it will be very critical of the hospital and managers.
"But if the whole inquiry operates on the wrong premise [of Letby's guilt] then everything that follows it in error and undermined. The government must not implement any recommendation until the Court of Appeal have seen and heard the new evidence. It’s a shame the Inquiry did not engage with any of the evidence of innocence gathered in the last two years."
Asked how Letby is feeling right now, he said: "Lucy is completely focussed on proving her innocence."
Recap: Hospital boss arrested for perverting course of justice in Lucy Letby baby deaths probe
09:30 , Nicole Wootton-CaneDetectives have arrested a senior hospital boss on suspicion of perverting the course of justice in connection with the inquiry into killer nurse Lucy Letby.
Cheshire Constabulary said a search warrant was carried out at a property in April.
A person was arrested and later bailed, pending further inquiries.
In July 2025, three members of the leadership team at the hospital, who occupied senior positions between 2015 and 2016, were arrested on suspicion of gross negligence manslaughter.
It is understood that the suspect arrested on suspicion of perverting the course of justice was one of the three arrested last year.
You can read more below:
Suspect arrested for perverting course of justice in Lucy Letby baby deaths probe
What is a whole life order - and why is Letby serving 15?
09:10 , Nicole Wootton-CaneLucy Letby was sentenced to 14 whole life orders after she was convicted of murdering seven babies and attempting to murder six others.
She was then handed a 15th whole life order after she was found guilty of trying to kill a premature baby girl after a retrial.
A whole life order is the most severe prison term that can be given, and means she will never be considered for release unless there are exceptional compassionate grounds to warrant it.
When will the Thirlwall Inquiry report be published?
08:50 , Nicole Wootton-CaneThe Thirlwall Inquiry is due to be published at 12:30pm on Tuesday.
It will examine how Letby was able to repeatedly kill and harm babies on a hospital neonatal unit in Chester between June 2015 and June 2016.
Watch: Lucy Letby: Who is she and why was she convicted of murder?
08:30 , Nicole Wootton-Cane'Inquiry has operated on wrong premise if Letby is innocent', says defence lawyer
08:07 , Harriette BoucherLucy Letby’s defence lawyer has said that the public inquiry being published today has been operating “on the wrong premise” if she is innocent.
Mark McDonald submitted nearly 30 expert reports to the Criminal Cases Review Commission (CCRC), which he told BBC “undermine the whole safety of the convictions”.
The chairwoman of the CCRC has told the broadcaster that the organisation would be paying close attention to the report.
Letby has already been denied permission to appeal against her convictions on two occasions.
"If she is innocent, as I believe, as 30-odd experts believe, then everything that has gone before the inquiry and every recommendation has operated on the wrong premise,” Mr McDonald said.
Experts quit Letby's defence team over 'scientific credibility' concerns
07:49 , Harriette BoucherTwo experts on Lucy Letby’s defence team have quit after claiming there were concerns about the “scientific credibility” of some of the evidence.
Professor Geoff Chase, from the University of Canterbury in New Zealand, and chemical engineer Helen Shannon, withdrew on Monday.
The experts had previously produced a 100-page report last year casting doubt on her convictions for poisoning two babies with insulin.
They said they still maintained it was “very unlikely” that two babies were poisoned, but felt some of the arguments being put forward on her behalf were “inconsistent with the available evidence, science and established physiology”.
Letby’s defence law Mark McDonald told Newsnight he was “sad that they've gone” but insisted those experts still believed “Lucy Letby is innocent”.
Doctor accused of being Lucy Letby ‘crush’ named for first time
07:43 , Harriette Boucher
Doctor accused of being Lucy Letby ‘crush’ named for first time
What is the Thirlwall Inquiry?
07:36 , Harriette BoucherThe Thirlwall Inquiry was launched in 2023 following Lucy Letby’s multiple convictions for murder and attempted murder of infants.
It was set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital.
The inquiry was not looking at whether Letby was guilty, but how concerns about the nurse from other staff were handled and whether her actions could have been prevented.
One of the country’s most senior judges, Lady Justice Thirlwall, heard evidence at Liverpool Town Hall from numerous witnesses between September 2024 and February 2025, including from the parents of Letby’s victims.
Lucy Letby public inquiry findings to be published
07:32 , Harriette BoucherThe findings from a public inquiry into how Lucy Letby was able to murder and harm babies is set to be published on Tuesday morning.
The Thirlwall Inquiry is due to look at what happened at Countess of Chester Hospital that led to the former neonatal nurse’s convictions for the crimes between June 2015 and June 2016.
Its key objectives were to seek answers for the victims’ families and ensure lessons are learned – some 25 years after another nurse, Beverley Allitt, committed similar crimes on a children’s ward in Grantham, Lincolnshire.
