Lucy Letby: Damning report finds babies killed "could have been saved"
The Thirlwall Inquiry has examined how the killer nurse was able to murder and harm babies at the Countess of Chester hospital
Last updated 15th Sep 2026
The final report into the crimes committed by killer nurse Lucy Letby has found some babies she killed could have been saved, had police been alerted to hospital deaths.
The Thirlwall Inquiry has examined how she was able to murder and harm babies at the Countess of Chester hospital.
Letby, from Hereford, who maintains her innocence, is serving 15 whole-life terms for the murders of seven babies and attempted murders of seven others by various means between June 2015 and June 2016.
She was twice denied permission to appeal against her convictions in 2024.
What has the inquiry looked at?
One of the country’s most senior judges, Lady 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’s key objectives were to seek answers for the victims’ families and ensure lessons are learned – some 25 years after another nurse, Beverley Allitt, committed similar crimes on a children’s ward in Grantham, Lincolnshire.
Lady Justice Thirlwall's investigation 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 inquiry examined whether suspicions should have been raised earlier and whether the police and other external bodies should have been informed sooner.
It looked at the response to concerns about Letby and whether the culture, management and governance structures and processes of the hospital trust, and the wider NHS, contributed to the failure to protect babies from Letby.
The inquiry also heard evidence about whether the accountability of senior managers should be strengthened.
What has the inquiry found?
The report states that there has been a ‘complete failure to protect babies’ at the Countess of Chester Hospital.
The first death took place on the 08th June 2015. In the lead up to that, the report found deaths on the hospital's neonatal unit were consistently low.
The highest amount of deaths between 2010 and 2014 was three in one year - that number rose to eight in 2015.
Letby was charged in connection with five of those deaths.
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.”
Parents "kept in the dark"
Lady Justice Thirlwall said it was “the wrong call” for the hospital not to keep parents informed about the police investigation.
She said: “Once the police were investigating the circumstances of the deaths of and injuries to their babies, the parents had the right to know about it.
“They should have been informed.”
In July 2016, the mother of baby C found out about a review by the Royal College of Paediatrics and and Child Health (RCPCH) which followed an increase in deaths on the neonatal unit after a friend alerted her to an article in the local newspaper, the inquiry heard.
Hospital staff told her it was a “formality” because of a small increase in the number of deaths, she said.
In her report, Lady Justice Thirlwall said: “This was not a question of balance, Mother C was being misled.
“It was not a question of not getting the communication right; it was about not being straight with parents who had the right to know what was going on.”
In his evidence to the inquiry, medical director Ian Harvey accepted that communication with families about a report carried out by consultant neonatologist Dr Jane Hawdon was “both crass and inappropriate”.
Lady Justice Thirlwall said: “This was a complete apology for the abject failure of communication with the parents in respect of Dr Hawdon’s report.”
Changes recommended to NHS rules
17 recommendations have been made by Lady Justice Thirlwall.
They include fitting all cots and incubators in neonatal units with baby monitors so that parents can observe babies remotely at any time.
CCTV cameras should be directed to spaces storing insulin and digital devices should be used to restrict access to authorised people.
By 31st March 2027 all hospital trusts must have effective mechanisms in place for board level monitoring of all deaths of children and infants.
By the same date NHS England must produce and distribute a one page protocol setting out steps to be taken when concerns are raised that a healthcare professional may have deliberately harmed a patient.
Part of the report looked into how well communication was between staff at the hospital and their operating techniques.
It was found there was almost no contact between senior managers and the neonatal unit.
One of the key concerns of the report was that it was not understood that the sudden unexpected death in infancy and child processes applied to the sudden and unexpected death of a baby in hospital.
The Countess of Chester Hospital NHS Foundation Trust's response to the Thirlwall Inquiry
Chief Executive Officer at the Countess of Chester Hospital NHS Foundation Trust, Jane Tomkinson OBE, said: “Today, as the Thirlwall report is published, our thoughts remain fully with all of the families and the babies who came to harm or who died because of Lucy Letby’s crimes at the Countess of Chester Hospital in 2015 and 2016. We recognise the enduring impact on them and the courage and dignity they have shown in ensuring their experiences are heard.
“We know that no apology or action can undo what happened at our hospital. We are however truly sorry for the events that occurred in 2015 and 2016. We acknowledge the findings of the Thirlwall Report and will approach its recommendations, with openness and a firm commitment, to build on the progress we have already made in improving our hospital’s governance, safety and culture since that time. We are a different organisation today, with new leadership, stronger governance and safety processes and a more open culture, where speaking up is encouraged and acted upon. We firmly believe that the changes we have made, as set out in our evidence to the Inquiry, have created a safer environment for our patients and staff.
“We acknowledge, however, that there is more to be done. We will now carefully consider the entire content of the Thirlwall Report and its recommendations, working with NHS colleagues, to embed the learning locally and across the wider NHS. Our priority is to ensure that we address the Thirlwall Report’s recommendations as swiftly as possible, whether through ensuring that actions we have already taken are sustained, or by taking further action where needed.
“We recognise the contributions of the families and everyone who gave evidence, including many of our staff. We have co-operated, openly and fully, with the Thirlwall Inquiry and we are grateful to Lady Justice Thirlwall and her team for the diligence and care, with which they have conducted the Inquiry.
“We are proud of our staff and their commitment to providing high-quality patient care. They are the heart of our organisation and their professionalism, compassion and resilience are central to the care we provide to patients every day.
“What took place at the Countess of Chester Hospital NHS Foundation Trust in 2015 and 2016 and the impact it had on so many people will not be forgotten. We will always remember.”