There was a “complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital,” the Thirlwall Inquiry report has found.
Some babies could have been saved from death or harm by Lucy Letby if safeguarding action had been taken earlier, the report added.
Lady Justice Thirlwall’s report examined events at the Countess of Chester Hospital that led to the former neonatal nurse’s convictions for the crimes between June 2015 and June 2016.
Lady Justice Thirlwall said her report into how Lucy 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”.
Letby, 36, is serving 15 whole-life orders after she was convicted at Manchester Crown Court of murdering seven infants and attempting to murder seven others.
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.
Lawyers representing several families affected said it is “vital” the report’s recommendations are implemented by the government.
Key Points
- 'Complete failure' to protect babies at Chester hospital, report finds
- Parents of Lucy Letby’s victims ‘kept in the dark’ about suspicions
- Harmed families say Thirlwall recommendations must be implemented
- Baby monitors and CCTV cameras – Thirlwall Inquiry issues recommendations
- Thirwall Inquiry report - what does it mean for Letby's defence
'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.
