Judge describes ‘complete failure at all levels’ to invoke safeguarding procedures
The judge said that her report, which has been laid out to parliament, describes “dysfunctional management and governance, a gulf between hospital leadership and clinicians and failure to understand the fundamentals of safeguarding”.
Speaking at Liverpool Town Hall just after her report was published, Lady Justice Thirlwall added that:
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.
Key events
‘This cannot be allowed to happen again,’ lawyer representing families says
Meanwhile, Richard Scorer, head of abuse law and public Inquiries at Slater and Gordon, who acts for three of the affected families, said:
The families I represent were looking for a clear analysis of what went wrong and strong recommendations to prevent this happening again.
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.
Reacting to the publication of the report, Lucy Letby’s barrister, Mark McDonald, said it was “particularly regrettable” that his client could not participate in the inquiry.
In a statement, he 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.
Here are some of images being sent to us from outside Liverpool Town Hall, , where the Thirlwall inquiry has been held:
Josh Halliday
The Guardian’s north of England editor, Josh Halliday, has been reporting from Liverpool Town Hall, where the report was delivered:
As Thirlwall delivered her remarks, a group of about 30 protestors held placards and chanted “No babies were murdered” outside Liverpool town hall.
Nicky Robinson, a retired nurse, said she deliberated about whether to attend the demonstration as she was concerned about upsetting the families of the babies.
However, the 59-year-old said she passionately believed that Letby had been made a “fall guy” and that “the truth must come out about how these children died”.
“I don’t want to upset any families but Lucy deserves a fair trial. I’ve worked with bereaved families and it’s terrible but the truth must come out about how these children died.”
Another protestor, Bernie Rowlands, had travelled nearly 200 miles from Gloucestershire to the demonstration. He had followed the case from the beginning because he used to live near Hereford, where Letby grew up.
Rowlands, 64, said: “I feel desperately sorry for (the families of the babies) but I would say that the police and certain newspapers have made their grief continue by pushing the guilty narrative. There’s no evidence here as far as I’m concerned.”
Lady Justice Thirlwall said work done by the inquiry showed 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 added:
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.
We are expecting the health secretary, Yvette Cooper, to deliver an oral statement reacting to the inquiry’s findings at 3pm. She may lay out the government’s position on some of the report’s recommendations then.
What were some of the recommendations made in the report?
Jamie Grierson
A 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 Thirlwall, the inquiry chair, 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 roadmap” for how it could be implemented by 31 March next year.
You can read the full list of recommendations here.
Families must not become ‘collateral damage’ in public argument on whether Letby is guilty, judge says
The judge highlights the dignity and bravery of the parents who gave evidence to the inquiry. The families cannot be named for legal reasons as a court order prohibits reporting of the identities of the surviving and dead children involved in the case.
She urged “everyone commenting on the events” at the hospital to “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”.
Their “dignity and courage should be respected by everyone”, she added, warning that the families should not become “collateral damage” in the public debate about whether Lucy Letby is guilty or not.
Parents ‘kept in the dark’ for years, judge says
Josh Halliday
The inquiry, which received evidence from nearly 400 witnesses, found that parents were “kept in the dark” for years about what happened to their babies and the concerns they may have been deliberately harmed. This was “reprehensible”, Thirlwall said.
Despite the concerns of senior doctors, the inquiry found that the hospital’s risk and patient safety department took no action until the end of June 2016, when two twin boys died unexpectedly. Thirlwall said the department “failed in its fundamental task to enhance patient safety”.
The inquiry chair accused hospital executives of overseeing “an exercise in spin” by downplaying the rise in deaths to the board of directors.
Their failure to contact police before April 2017 – nearly two years after the unexplained increase in deaths – suggested that protecting the hospital’s reputation was “prized more highly” than the doctors’ concerns, she found.
Lady 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, she said.
She said:
After the death of Baby I suspicions became clearer. 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.
Lady Justice Thirlwall said that senior nurses at the hospital refused to accept the consultant’s concerns could be justified, and criticised the “prolonged delay by senior managers in calling the police”.
The police were eventually contacted in May 2017, around a year from the death of baby P in June 2016, and despite the fact Letby had been removed from neonatal unit.
The report is also critical of the internal and external reviews commissioned by hospital leadership after concerns were raised about Letby, which the judge said did not address whether “deliberate harm” was being caused or not.
Judge describes ‘complete failure at all levels’ to invoke safeguarding procedures
The judge said that her report, which has been laid out to parliament, describes “dysfunctional management and governance, a gulf between hospital leadership and clinicians and failure to understand the fundamentals of safeguarding”.
Speaking at Liverpool Town Hall just after her report was published, Lady Justice Thirlwall added that:
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.
Lucy Letby public inquiry report published
The report has been published now. You can read it in full here. Lady Justice Thirwall has began her address. We will bring you the highlights of what she said.
Three babies may have survived if hospital had acted over Lucy Letby concerns, inquiry finds
Josh Halliday
Three babies may have survived and seven others could have been protected if hospital bosses and doctors had taken action over concerns about the nurse Lucy Letby, an official inquiry into the deaths has concluded.
A public inquiry led by Lady Justice Thirlwall found a “complete failure” to protect babies on the neonatal unit at the Countess of Chester hospital in north-west England.
In a series of devastating findings, the judge said two newborn twins would not have died and five others would not have been harmed if Letby had been removed from the unit sooner.
Thirlwall said a third baby, a two-month-old girl, and two others who suffered unexplained collapses may have been protected if a doctor had detected an earlier insulin poisoning on the unit. One of those infants, now aged 11, suffered a lifelong brain injury and needs 24-hour care. You can read more here:
We are expecting the Thirlwall Inquiry report to be published here in five minutes.
The document is said to be huge, running into hundreds of pages, and will likely describe widespread failings in safeguarding at the Countess of Chester hospital, where Lucy Letby worked.
The Guardian’s north of England editor, Josh Halliday, is at Liverpool town hall, which is the venue for the first reading of the report. He is among the members of the media who were allowed access to the report this morning, and we will be able to report the findings shortly.
Lady Justice Thirlwall is expected to deliver a televised statement just after 12.30pm, which you can watch live here or at the top of the blog:
Letby’s barrister insists case has not been undermined despite experts quitting
Mark McDonald, Lucy Letby’s barrister, yesterday appeared on BBC Newsnight and reacted to the news that two members of the former nurse’s defence team had withdrawn earlier in the day over concerns about the “scientific credibility” of some of its evidence.
As a reminder, the defence team has submitted evidence to the Criminal Cases Review Commission (CCRC), which is reviewing material relating to Letby’s convictions.
Asked by the programme whether the expert’s withdrawal undermined Letby’s case, 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 told the BBC. “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.”
McDonald said previously that the recommendations made in the Thirlwall inquiry report will be “significantly undermined” when his client is “found innocent of all crimes” and has criticised the process a waste of taxpayers money.
The overall cost of the inquiry – from its commencement in September 2023 to the end of March 2026 – is at least £18,718,000, according to an answer to a parliamentary question.
Experts quit Lucy Letby’s defence team a day before inquiry report is published
Josh Halliday
Two experts withdrew from Letby’s defence team on Monday. They said that although they stood by their assessment that it was “very unlikely” two of the babies were poisoned, some of the arguments being put forward on her behalf were “inconsistent with the available evidence, science and established physiology”.
Helen Shannon, a British chemical engineering expert, and Geoff Chase, a professor of bioengineering based in New Zealand, produced a 100-page report last year casting doubt on her convictions for poisoning two babies with insulin.
They told the Guardian last year there was a “very strong level of reasonable doubt” about those two convictions, which formed a central part of the prosecution case against Letby. The 36-year-old nurse was convicted in 2023 of trying to murder two newborn boys, known as Baby 6 and Baby 12, by spiking their feeding bags with insulin.
Letby is serving 15 whole-life orders after she was convicted across two trials at Manchester crown court of murdering seven babies and attempting to murder seven others, with two attempts on one of her victims, between June 2015 and June 2016.
Shannon and Chase said on Monday they stood by their assessment, but could not support other evidence used by Letby’s defence team relating to the insulin cases. You can read the full story here:
What crimes was Lucy Letby convicted of?
My colleagues Jamie Grierson and Josh Halliday have summarised the crimes Lucy Letby has been convicted of in a useful explainer I have linked to at the bottom of this post.
In August 2023, Letby was found guilty of murdering seven babies and attempting to kill six more, making her the worst child serial killer in modern British history.
Her victims included two identical triplet brothers, killed within 24 hours of each other, a newborn weighing less than 1kg (2lb) who was fatally injected with air, and a girl born 10 weeks premature who was murdered on the fourth attempt.
The jury was unable to reach verdicts on six further counts of attempted murder, relating to five babies. She later faced retrial on one count of attempted murder.
In July 2024, Letby was found guilty of trying to kill a two-hour-old baby girl on the same hospital ward where she murdered seven other infants.
The infant, known as Baby K, was born 15 weeks premature and weighed only 692g when Letby tampered with her breathing tube, causing a “life-threatening” deterioration. Letby was sentenced to another whole-life order.
Lucy Letby was moved from the neonatal unit to administrative duties in July 2016 after consultants expressed concerns about her to the hospital’s executive team.
Hospital bosses opted to carry out a number of reviews into the increased mortality in 2015 and 2016, but did not invite Cheshire Constabulary to investigate until May 2017, as Letby remained on site until her arrest more than a year later.
Lucy Letby inquiry report to be published after repeated delays
The findings of the long-awaited Thirlwall inquiry – set up to examine how the former nurse Lucy Letby was able to murder babies at a neonatal unit over a two-year period – is set to be published early this afternoon.
Letby, now 36, was convicted of murdering seven babies and attempting to murder seven more in 2015 and 2016, when she worked as a nurse in the neonatal unit of the Countess of Chester hospital.
She was sentenced to 15 whole-life orders, and was twice denied permission to appeal against her convictions in 2024.
However, the Criminal Cases Review Commission, which investigates potential miscarriages of justice, is considering evidence presented on Letby’s behalf by an international panel of medics who claim poor medical care and natural causes were the reasons for the babies collapsing.
Letby has always protested her innocence and there have been some reports casting doubt on the safety of her convictions. A number of doctors, scientists and statisticians have publicly challenged the way the evidence was presented to jurors at her trial.
The public inquiry, chaired by one of the country’s most senior judges, Lady Justice Thirlwall, was formally established in October 2023 by the former health secretary Steve Barclay, two months after Letby’s multiple convictions.
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.
The inquiry did not examine Letby’s convictions or possible motives, focusing instead on the conduct of those working at the Countess of Chester Hospital, including managers, nurses and midwives, with regard to Letby’s actions, whether Letby should have been suspended earlier, if police should have been informed sooner of suspicions about her, and whether her managers should have responded differently when concerns about her were first raised.
The inquiry has also considered how effective NHS management and governance structures were, and what information parents received regarding their babies’ care. It says its aim is to seek “answers for the victims’ families” and ensure that “lessons are learned”.
The report was first expected to have been published in November 2025 but was set back by a string of delays.
Inquests into the deaths of babies who Letby was convicted of murdering are to take place in May 2027.
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