Three babies murdered by Lucy Letby could have been saved - as inquiry finds 'complete failure' to protect infants on neonatal unit
'Complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital' found in inquiry
Three babies could have been saved from death and harm at the hands of Lucy Letby if safeguarding action had been taken earlier, according to the findings of a damning public inquiry.
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The Thirlwall Inquiry was launched in 2023 in the wake of the former nurse’s multiple convictions for murder and attempted murder of infants at the Countess of Chester Hospital.
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.”
The report found that three deaths could have been prevented if “action” had been taken earlier and NHS bosses had contacted police sooner.
Instead of alerting the police, bosses prioritised the reputation of the hospital over the babies’ safety by commissioning external investigations which failed to discover why they were dying.
Relationships between the consultants raising concerns and executives 'disintegrated' as a result, the judge said.
Lady Justice Thirlwall, one of the country’s most senior judges, went on: “How many lives could have been saved had the hospital acted differently? This is something we will never know for sure.
“It is clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier.”
The Care Quality Commission regulator has also admitted it “did not take an approach which was sufficiently investigative and inquiring” when it inspected the Countess of Chester Hospital.
Dr Toli Onon, who joined the CQC as chief inspector of hospitals last year, said: “We are truly sorry for the fact that there were significant shortfalls in CQC’s document management that impacted the evidence we were able to provide to the Inquiry.
“An independent external review of our information and records management practices has since been undertaken, and learning from that review is being used to improve CQC’s information management practices and document management systems."
The inquiry did not examine Letby’s convictions or motives but instead focused on the conduct of those working at the Countess of Chester, including the board, managers, doctors and nurses from when Letby started her employment in 2012.
Letby, 36, 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, and did not invite Cheshire Constabulary to investigate until May 2017, as Letby remained on site until her arrest more than a year later.
The Thirlwall report found that senior nurses never accepted that the consultants’ concerns were, or might be, justified, and that there was a prolonged delay by senior managers in calling the police.
It ruled that successive internal and external reviews commissioned by hospital leadership after concerns were raised about Letby did not address whether deliberate harm was being caused or not.
A total of 14 recommendations have been made in the report including the fitting of baby monitors in all cots and incubators in neonatal units and CCTV cameras focused on insulin storage fridges.
Lady Justice Thirlwall 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 March 31 next year.
She also said digital devices should be used to “restrict access of insulin to authorised people”, as well as recording access to insulin units.
Another recommendation was that all managers be subject to an “individual duty of candour to all patients and colleagues”, and that a code of conduct for senior managers should “set out, at the beginning, the uncontroversial duty of every manager to put patients first.”
The chairwoman also ruled that parents of Lucy Letby’s victims were “kept in the dark” about suspicions by the hospital.
Families of the babies were not aware of concerns until the nurse was arrested and they were contacted by police in July 2018, the report concluded.
She said: “I would like to thank the parents of all the babies who died or were injured.
“Their evidence, generously given, was amongst the most thoughtful and moving any person will ever hear.
“Throughout a very difficult and prolonged process, the parents have conducted themselves with dignity and determination, with the aim that no other parents should have to experience such grief and heartache.”
In a joint statement, Sue Hodkinson, Alison Kelly, Ian Harvey and Tony Chambers, the former senior managers at the Countess of Chester Hospital, said: “”We are carefully reviewing the Thirlwall report and its recommendations.
“Given that there are a number of investigations under way, and that the work of the Criminal Cases Review Commission has not yet completed, it would be inappropriate for us to offer any further comment at this time.
“Our thoughts remain with the families affected by the tragic events that took place at the Countess of Chester Hospital.”
