The Lucy Letby inquiry concluded that dysfunctional management and a complete failure to safeguard patients at a northwest England hospital meant some babies could have been saved from death or injury, according to a report released Tuesday by Justice Kathryn Thirlwall.
The judge said staff at the Countess of Chester Hospital missed crucial opportunities to act when infants began collapsing in the neonatal unit. “Errors were made by nurses, doctors and managers,” Thirlwall said, adding there was a “complete failure at all levels” to trigger safeguarding procedures.
The inquiry, which heard from more than 130 witnesses and reviewed 400 statements over six months, did not revisit Lucy Letby’s convictions. Instead it examined how institutional shortcomings left babies repeatedly exposed to harm and how hospital leaders and staff handled concerns and treated families.
Lucy Letby inquiry details systemic failures
Thirlwall focused on the lack of intervention even as it became apparent someone was deliberately harming babies. “How many lives could have been saved had the hospital acted differently? It is clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier,” she said.
The judge found that parents were kept uninformed for years about concerns their children may have been deliberately harmed. She described their treatment as “reprehensible” and said hospital executives used the potential distress of families as a justification for not contacting police.
Letby, 36, is serving a whole-life sentence for murdering seven babies and attempting to kill seven others. She maintains her innocence, and a defense effort supported by dozens of scientists continues to challenge the evidence used to convict her.
In 2023, Letby was found guilty of murdering seven infants and attempting to murder six others, including two attempts on one child. After a retrial on a count that initially resulted in no verdict, she was convicted in July of another attempted murder. She received 15 life terms with no chance of release, becoming only the fourth woman in the United Kingdom to receive such a sentence.
Thirlwall noted that if the babies Letby was convicted of murdering were excluded from the unit’s annual deaths, mortality would have been three in 2015 and three in 2016, figures broadly consistent with prior years.
Prosecutors said Letby harmed infants in ways that left minimal traces, including injecting air into bloodstreams, introducing air or milk into stomachs via nasogastric tubes, administering insulin, and interfering with breathing tubes. She was the sole employee on duty in the neonatal unit when the children collapsed or died between June 2015 and June 2016, which prosecutors described as a “constant malevolent presence.”
