Lucy Letby inquiry 7 bombshells - 'babies could have been saved' as heartbreaking missed chances revealed

There was a “complete failure to protect babies” at the hospital where serial killer Lucy Letby worked, a scathing report has concluded. The collapse and deaths of some babies could have been avoided had safeguarding practices been followed, it said. The report says “we will never know for sure” how many lives could have been saved if the hospital acted differently, adding: “It is clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier.” The report calls for urgent changes to protect babies, as inquiry chair Lady Justice Thirlwall said: “This must never happen again.” She also praised the “dignity and courage” of the parents, thanking them for sharing their experiences with the inquiry. But she said the “lack of consideration shown to parents” by hospital management was “reprehensible”. Inquiry chair statement Delivering her findings she said: “My report describes dysfunctional management and governance; a gulf between hospital leadership and clinicians; and failure to understand the fundamentals of safeguarding. “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.” Letby, 36, was convicted of killing seven babies and attempting to murder seven more, with two attempts on one of her victims, while working on the neonatal unit at the Countess of Chester Hospital in 2015-2016. She received 15 whole-life orders. The report states since 2015-16 there has been only one death on the neonatal unit, in Sept 2019. The inquiry urged people commenting on the report to remember that families have “suffered grievously and continue to suffer as a result of the unexpected collapses and in some cases deaths of their babies”. It said in the 10-11 years since then “their dignity and courage should be respected by everyone”. Senior nurses never accepted concerns The report found that senior nurses never accepted consultants’ concerns were - or might be - justified, and there was a prolonged delay by senior management in calling the police. It said successive internal and external reviews commissioned by hospital bosses “did not address whether deliberate harm was being caused or not". Rather than believe the concerns being raised ,“clinicians themselves were made subject of investigation within Letby’s grievance process”, it stated, with three consultants told to apologise to her. The report reflects the anger some parents felt at the way they were treated by the hospital. 'Kept in the dark for years' It says: “They were kept in the dark for years about what was happening and about the fact there were concerns that their babies may have been deliberately harmed.” Their consent was not obtained before sharing medical records with external experts and other organisations and they were not informed about reviews. Only in 2018 did they learn the collapses and deaths may have been the result of actions of a nurse in whom they had put their trust. It says: “Many parents too the view that protecting the reputation of the hospital was more important to senior managers than keeping them informed about what was happening. The lack of consideration shown to parents at that time was reprehensible.” 17 urgent reforms The report gives 17 recommendations for urgent reforms in the operation and supervision of NHS neonatal units. It says the hospital’s safeguarding policy did not mention the possibility of deliberate harm by a staff member - and there is still no NHS-wide protocol on deliberate harm. The NHS must follow schools and social care providers who have accepted the possibility of malicious actions and know how to manage concerns. Other recommendations include all cots and incubators in neonatal units being fitted with baby monitors, so parents can observe their baby remotely at any time. Trusts should install CCTV cameras directed at fridges or other units storing insulin. And by March 2027 all hospital Trusts must have in place effective mechanisms for board-level monitoring of all deaths of children and babies, with a clear route to the board for the escalation concerning data trends or patterns. Should suspicions have been raised? The Thirlwall Report asks ‘should suspicions have been raised earlier?’ and ‘what were the responses to concerns raised about Letby?’ Lady Justice Thirlwall wrote: “I start by acknowledging that the idea that anyone would deliberately harm and even kill tiny babies is repugnant. That a nurse would do so is often said to be unthinkable. Because it is too hard to accept, declaring something unthinkable avoids having to confront it.” Citing the cases of Harold Shipman and Beverly Allitt, she says: “We know that sometimes, albeit very rarely, nurses and doctors deliberately harm and kill patients, including very young children and very elderly people.” Letby, 36, was convicted of killing seven babies and attempting to murder seven more, with two attempts on one of her victims, while working on the neonatal unit at the Countess of Chester Hospital in 2015-2016. She received 15 whole-life orders. The report says suspicions were first raised in October 2015, following the death of Baby I. It states the death "caused a shift in the attitude of some paediatricians. Corridor conversations about Letby began". The report says if action had been taken - and Letby moved off the ward - then the deaths of babies O and P would not have occurred, and neither would the attacks of babies J, K, L, M and N. Lady Justice Thirlwall’s findings say it is possible to go back even further, to baby F, in August 2015. During the inquiry Dr ZA stated she “deeply regretted” not recognising or flagging signs of deliberate harm. She recalled seeing abnormal blood test results for Baby F - which showed high insulin and low C-peptide levels indicating outsider poisoning - but dismissed the possibility because it felt “so fantastical and unlikely”. She testified that hospital executives pressured pediatricians to stop raising concerns about Letby. Missed chances The inquiry states actions should have been taken at this stage, which would have also stopped attacks on baby G, H and I. The report states: “There were further occasions when suspicions should have been flagged in a way that ought to have triggered safeguarding action; but theses were also missed”. It said in February 2016 Dr Ravi Jayaram should have reported what he witnessed with baby K. The inquiry heard he walked into the intensive care unit and found Letby standing alone over the baby. The baby’s blood oxygen levels were dropping dangerously, but no alarms were sounding and Letby was not intervening or calling for help. He gave the baby breaths, and stabilised her. He later concluded the baby's breathing tube had been deliberately dislodged. Dr Jayaram told the inquiry; “I should have been braver and should have had more courage because it was not just an isolated thing. There was already a lot of other information.” Following the incident with Child K, Dr Jayaram said the fears of Letby causing deliberate harm had become “an elephant in the room which was becoming bigger and bigger”. Letby went on to murder Child P, a baby boy, before she was finally moved from the neonatal unit to clerical duties in July 2016, after the consultants expressed similar concerns to the hospital’s executive team. Hospital bosses then opted to carry out a number of reviews into the increased mortality and did not call in Cheshire Police to investigate until May 2017. The inquiry found another missed chance to step in following insulin poisoning to baby L in April 2016. It states: “Each of these instances, and crucially the first, were sufficient to arouse suspicion sufficient to warrant safeguarding action.” Senior management held a meeting on May 11, 2016, where the possibility of either incompetence or deliberate harm was raised. The inquiry heard that in the meeting neonatal clinical lead Dr Stephen Brearey met with the hospital's medical director, Ian Harvey, and director of nursing, Alison Kelly. He highlighted that the high number of infant deaths was “exceptional”, noting an unusual pattern - six out of nine cardiac arrests occurred between midnight and 4am — and explicitly stated that after multiple care reviews, the only common factor was that Letby was on duty. The report says they took a “wait and see” approach and this “risked the lives of babies who were likely to come onto the unit”. Letby went on to kill two more babies (O and P) in June 2016 when she injected them with air. It states: “The Chief Executive (Tony Chambers) was unaware of what was happening on the neonatal unit until after the deaths of baby O and P. After this he added to the unnecessary delay in contacting the police.” 'Dreadful communication' The inquiry also found the way hospital executives communicated with parents whose babies were killed by Lucy Letby was “dreadful”. Hospital chiefs used the excuse of upsetting grieving families as a “convenient argument” to justify not calling the police, it said. Several parents told how they were given leaflets about bereavement - but no other recognition of their situation and no support. The Thirlwall Inquiry also found families weren’t told about investigations into the deaths of their children - while some were misled in face-to-face meetings or in letters from the hospital. It states: “Parents were not aware of any concerns that an individual had caused neonatal deaths and collapses at the Countess until Letby was arrested and the police contacted them in July 2018.” One mother said she had “mixed feelings” when she heard consultants had made allegations about a nurse. She said: “I’m forever grateful because the consultants did speak up and did say something, but it’s also very sad that nothing was ever shared with us.” Some parents told the inquiry they were shown to a family room following the deaths of their babies - but it was within the labour ward where the cries of other tots could be heard. The reports says while this was “wholly unintended” it still caused “desperate heartache”.