Thirlwall Inquiry: Some Lucy Letby baby murders could have been prevented
The Thirlwall Inquiry concluded that failings at the Countess of Chester Hospital allowed Lucy Letby to murder babies, with some deaths potentially preventable.
The Full Story
A plain summary built from the channels that reported this story.
The Thirlwall Inquiry has published its final report into how former neonatal nurse Lucy Letby was able to murder seven babies and attempt to murder seven others at the Countess of Chester Hospital between 2015 and 2016. The report, led by Lady Justice Thirlwall, concluded that there was a 'complete failure' to protect babies on the neonatal unit and that some deaths could have been avoided if safeguarding action had been taken earlier.
The report described dysfunctional management and governance, a gulf between hospital leadership and clinicians, and a failure to understand the fundamentals of safeguarding. It found that doctors' concerns about Letby were dismissed, with some clinicians who raised the alarm being investigated themselves. Senior managers at the hospital were criticised for delaying the police investigation and prioritising the hospital's reputation over patient safety. Lady Justice Thirlwall said the lack of consideration shown to the parents of the babies was 'reprehensible'.
The inquiry made 17 urgent recommendations, including installing live-streaming cameras in all cots and incubators in neonatal units, restricting access to insulin, and creating a new NHS-wide protocol for dealing with suspicions that a member of staff may be causing deliberate harm. The government has said it will act on the recommendations, with the Health Secretary Yvette Cooper calling it a 'turning point' for the NHS.
The families of the victims have welcomed the findings but say the real test will be whether the recommendations are implemented. The report also comes amid ongoing investigations, including the Criminal Cases Review Commission review of Letby's convictions and a police investigation into potential corporate manslaughter at the hospital. Supporters of Letby continue to question her guilt, but the inquiry was not tasked with examining her convictions.
The Countess of Chester Hospital has said it acknowledges the findings and is committed to making improvements.
On screen
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Key Claims
Claims reported during this story's coverage, mapped by channel. Ordered by how many channels carried each claim.
| Claim | Channel 5 | BBC News | BBC One | BBC Two | Channel 4 | GB News | ITV | Sky News |
|---|---|---|---|---|---|---|---|---|
| The report found that some babies' deaths could have been avoided if action had been taken sooner. | · | · | ||||||
| The inquiry report is expected to conclude that there were widespread failings in safeguarding at the Countess of Chester Hospital. | · | · | · | |||||
| The report made 17 recommendations for all NHS neonatal units. | · | · | · | |||||
| Senior doctors had concerns about Letby, and it took months for her to be removed from duty and almost a year before police were called. | · | · | · | · | · | |||
| The hospital's failure to call police sooner was described as indefensible. | · | · | · | · | · | |||
| The report recommended installing cameras or monitors in neonatal cots. | · | · | · | · | · | |||
| Inquiry described dysfunctional management and governance at the hospital. | · | · | · | · | · | · | ||
| Lucy Letby is serving 15 whole life orders for murdering seven babies and attempting to murder seven others. | · | · | · | · | · | · | ||
| Parents were kept uninformed for years about concerns over deliberate harm. | · | · | · | · | · | · | ||
| The government promised to introduce cot cams. | · | · | · | · | · | · | ||
| The Health Secretary said the report should be a turning point for the NHS. | · | · | · | · | · | · | ||
| The inquiry found a complete failure to protect babies at the hospital. | · | · | · | · | · | · |
Channel Perspectives
What each channel focused on, with key quotes.
The Newsnight segment focused on the legal challenge to Letby's convictions, featuring an interview with her defence barrister Mark McDonald, who discussed the withdrawal of two expert witnesses from his team and his confidence in the evidence submitted to the Criminal Cases Review Commission. The coverage gave prominence to the argument that the inquiry proceeded on a flawed premise of guilt.
- “I fundamentally disagree with it and more importantly 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”
- “So we're now left with one team of seven international experts from across the world that say she's innocent”
BBC News provided comprehensive coverage of the report, highlighting the 'complete failure' to protect babies, the 17 recommendations, and the government's response. It included reactions from families' lawyers and background on Letby's crimes, as well as the ongoing CCRC review.
- “The report describes dysfunctional management and governance, a gulf between hospital leadership and clinicians and failure to understand the fundamentals of safeguarding.”
- “There was also complete failure at all levels to invoke safeguarding procedures at any point.”
Sky News focused on the inquiry's conclusion that some babies could have been saved, provided a detailed timeline of Letby's arrests and trials, and highlighted the recommendations including cot cams. It included the hospital's response and the ongoing police investigation.
- “No one seems to have thought that safeguarding action is required when a member of staff is suspected of causing deliberate harm. It isn't necessary to be sure. Suspicion is enough.”
- “It is clear some babies would have been saved and some acts attacks prevented if action had been taken earlier”
Channel 4's coverage was particularly critical of systemic failures, drawing parallels with other NHS scandals in maternity care. They focused on the failure of senior managers and the need for lasting change, and included a strong line about the NHS being 'deadly' on the maternity front.
- “The NHS is supposed to care for us from cradle to grave. But on the cradle front, the system has once again been found to be not just 40, but in the case of convicted child killer Lucy Letby, deadly.”
- “The lives of three out of the seven babies could have been saved if the trust had been more concerned about patient safety and less about its reputation.”
The regional BBC station provided in-depth reporting, including a detailed timeline of missed opportunities, specific criticism of hospital executives, and an interview with a doctor who raised concerns. They also covered the day-after focus on implementing recommendations.
- “The lives of some babies could have been saved if action had been taken earlier by staff at the Countess of Chester Hospital.”
- “The report's scathing about the hospital's former executives.”
ITV News focused on the conclusion that up to three deaths could have been avoided, and provided analysis of ongoing legal processes including the CCRC and police investigation. They highlighted the emotional impact on families and the need for reform.
- “The long awaited inquiry into how Lucy Letby was able to murder seven babies and tried to kill seven more has found that up to three of those deaths could have been avoided.”
- “It condemns a them and us approach by nurse managers to doctors raising suspicions about Letby, a serious failure.”
5 News provided a straightforward report on the inquiry's findings, highlighting the 'complete failure' and the possibility that deaths could have been prevented. They also covered the demonstration by Letby's supporters and the ongoing reviews.
- “The final official report into her crimes says the deaths of some of the victims could have been prevented if stricter rules had been followed.”
- “Instead, there was a complete failure to protect babies on the neonatal unit where Letby worked.”
GB News provided opinion-led coverage, with presenters questioning whether lessons will be learned and debating the merits of recommendations such as cot cams. They also discussed the ongoing controversy over Letby's conviction and the influence of high-profile supporters.
- “The report found that the hospital bosses tried to control the narrative and basically removed all evidence, wherever they could, that counted against them.”
- “a cockcam is a Band-Aid measure”
Broadcast Timeline
News broadcasts tracked for this story, in time order.