At least three babies could have been saved from Britain’s worst child serial killer Lucy Letby if action had been taken sooner, a public inquiry has found.
Lady Justice Thirlwall said there was “a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital” while Letby was harming newborns in 2015 and 2016.
Letby, 36, is currently serving fifteen whole life orders for the murder of seven babies and attempting to murder a further seven.
During two trials, prosecutors said former neonatal nurse Letby harmed babies by poisoning them with insulin, injecting them with air and milk and causing physical trauma.
Letby has always maintained her innocence, but has twice had applications to overturn her convictions rejected by High Court judges.
The independent body the Criminal Cases Review Commission (CCRC) is the only remaining option for her to challenge her convictions and it is currently considering a fresh application.
1. At least three babies could have been saved
Lady Thirlwall said that no real safeguarding action began until after the death of Baby I in October 2015.
Even then, Letby was not moved off the ward.
A public inquiry into Letby’s crimes was conducted by Lady Justice Thirlwall in Liverpool (Photo: 2026 Getty Images)If she had, the deaths of Baby O and Baby P and the attacks on Babies J, K, L, and M between November 2015 and June 2016 would not have occurred, the report found.
Lady Thirlwall added that it is “possible” Letby could have been caught even earlier in August 2015. A medic known as Dr ZA had “disregarded” a result which showed abnormal levels of insulin in a baby after they had been poisoned.
If this had resulted in safeguarding action, the attacks on Babies G, H and the death of Baby I would not have occurred.
2. Whistleblower doctors ‘deprived of protection’
Letby was eventually moved off the ward and Cheshire Police called in after a prolonged period of disagreement between nurses, doctors and senior management about why babies were suffering unexpected collapses and dying.
Lady Thirlwall said that from the first meeting about the increase in baby deaths in June 2015, there was a “them and us” approach between nurses and doctors which should not have occurred and “distracted from the real issue”.
Doctors who did eventually speak out about their concerns with Letby were not protected by hospital managers and were even threatened with referral to regulators.
“Despite raising concerns in good faith, the consultants were deprived of protection from recrimination,” Lady Thirlwall said.
3. ‘Repeated failures’ from ‘foolhardy’ senior managers
Lucy Letby is serving 15 whole life terms after being found guilty of murdering seven babies (Photo: Cheshire Constabulary)There was also a lack of oversight from senior managers.
In September 2015, a meeting of the hospital’s Board of Directors said that the most senior doctor, medical director Ian Harvey, “personally” reviewed all deaths at the hospital.
Harvey admitted in evidence to the Thirlwall inquiry this wasn’t true and that in fact he reviewed only adult deaths, not those involving children.
Lady Thirlwall said that senior managers “repeatedly failed in the duty of candour in their dealings with the bereaved parents, investigators, or regulatory organisations”.
She said their behaviour was “high-handed, contrary to all safeguarding principles and foolhardy.”
Following Letby’s convictions, Cheshire Police launched a separate corporate manslaughter investigation and three former executives have been arrested. No charges have yet been brought.
4. Treatment of parents was ‘reprehensible’
Many parents of the babies who were harmed by Letby also tried to raise concerns – mainly about the poor care they felt they had received – but were ignored.
They were not informed when the hospital made important decisions, such as bringing in the police, and their children’s medical records were shared without their consent, the inquiry said.
Parents who gave evidence “took the view that protecting the reputation of the hospital was more important to senior managers than keeping them informed about what was the happening”, the inquiry said.
(Photo: Cheshire Constabulary/PA).The lack of consideration shown to parents at the time was “reprehensible”, said Lady Thirlwall.
5. Call for monitors to livestream video from neonatal hospital baby cots
Lady Thirlwall has made 17 recommendations as part of her report.
They include installing baby monitors in all cots and incubators in neonatal units which have livestreaming video so that parents can observe their baby at any time.
“This will deter someone who wants to harm a baby and parents will be reassured to be able to see their babies when they cannot be with them,” Lady Thirlwall said.
She said concerns about the costs, training and ‘workload’ implications of installing cameras are outweighed by the benefits.
Access to insulin storage in hospitals should be controlled by biometric data, the report said.
While this technology is being installed, insulin storage should be monitored by CCTV cameras.
By March 2027, all hospital trusts should have “effective” mechanisms for monitoring all deaths of children and babies with a “clear route” for the Board to escalate any concerns.
What this means for Letby’s appeal
Lucy Letby’s lawyers have vowed that she will be found “innocent of all crimes” despite the wide-ranging conclusions of the public inquiry.
Her only avenue to clearing her name is now an application to the Criminal Cases Review Commission (CCRC), an independent body which examines alleged miscarriages of justice.
Letby’s legal team, led by lawyer Mark McDonald, made a series of submissions to the CCRC last year from a panel of around 30 medical experts which he says casts doubt on the prosecution.
(left to right) Professor Neena Modi, barrister Mark McDonald, Sir David Davis MP and retired medic Dr Shoo Lee, during a press conference at 1 Great George Street, central London. Picture Tuesday February 4, 2025. PA Photo. See PA story LEGAL Letby. Photo credit should read: Ben Whitley/PA WireThe CCRC is now considering the evidence and said it cannot offer a timeline on when it will decide whether to progress Letby’s case or not.
A CCRC spokesperson said: “We’ll be looking at the report to assess whether it has a bearing on our review.”
Letby’s case suffered a blow this week when it emerged that two of the experts who had contributed to the CCRC dossier have now withdrawn their support.
Helen Shannon, a British chemical engineering expert, and Geoff Chase, a professor of bioengineering based in New Zealand, quit the campaign due to concerns about the “scientific credibility” of evidence being used, The Guardian reported.
McDonald played down the development, stating that Letby’s case does not “stand or fall on any one expert.”
Reacting to the public inquiry, he said that “it has been conducted on the premise that an innocent woman is guilty of crimes she has not committed.”
He said the £18.5 million spend on the inquiry “would have been far better spent on addressing the UK’s broken neonatal system and providing equipment and support to wards across the country”.
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