Babies murdered or harmed by Lucy Letby could have been saved if hospital bosses had acted sooner, a major public inquiry has concluded.
Lady Justice Thirlwall found there was a “complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital”, saying safeguarding action should have been taken when concerns emerged that a member of staff might be deliberately harming children.
The Thirlwall Inquiry was established following Letby’s convictions for murdering and attempting to murder babies at the hospital. It examined the conduct of the hospital’s board, managers, doctors and nurses rather than reconsidering Letby’s convictions or her motives.
Publishing her final report on Tuesday, Lady Justice Thirlwall said: “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.
“My report describes dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals of safeguarding.”
‘Some babies would have been saved’
Lady Justice Thirlwall said it would never be possible to establish precisely how many lives could have been saved had the hospital responded differently.
But she concluded: “It is clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier.”
Letby was removed from the neonatal unit and placed on administrative duties in July 2016 after consultants raised concerns with the hospital’s executive team.
Hospital bosses commissioned a series of reviews into increased mortality during 2015 and 2016, but Cheshire Constabulary was not invited to investigate until May 2017.
The inquiry found senior nurses never accepted that consultants’ concerns might be justified and identified a prolonged delay by senior managers in contacting police. It also concluded that reviews commissioned by hospital leadership failed to address whether deliberate harm was being caused.
Families ‘kept in the dark’
The report found the parents of Letby’s victims were “kept in the dark” about concerns surrounding the nurse.
Families were not made aware of the suspicions until Letby was arrested and they were contacted by police in July 2018.
Lady Justice Thirlwall thanked the parents for giving evidence, describing their accounts as among the most “thoughtful and moving” anyone could hear and praising their dignity and determination.
14 recommendations made
The inquiry has issued 14 recommendations, including baby monitors for every cot and incubator in neonatal units and CCTV cameras focused on insulin storage fridges.
It also recommended digital systems restricting insulin access to authorised staff and recording who accesses supplies, alongside an individual duty of candour for managers.
Letby, 36, from Hereford, is serving 15 whole-life orders after being convicted of murdering seven babies and attempting to murder seven others between June 2015 and June 2016.
She maintains her innocence. The Criminal Cases Review Commission is considering evidence submitted on her behalf by an international panel of medical experts.
