Lucy Letby inquiry - latest: Two babies murdered by nurse could have been saved

Lucy Letby inquiry - latest: Two babies murdered by nurse could have been saved Serial killer Letby, 36, was convicted of killing seven babies and attempting to murder seven more, with two attempts on one of those victims An inquiry into the crimes of killer nurse Lucy Letby - who was convicted of killing seven babies and attempting to murder seven more - has found some of the tragic deaths could have been avoided if hospital staff had acted differently. A scathing report has found there was a "complete failure to protect babies" at the Countess of Chester Hospital where Letby, now 36, worked between 2015 and 2016. It found that, if action had been taken, with Letby moved off the ward, then the deaths of babies referred to as O and P would not have occurred, and neither would attacks on babies J, K, L, M and N Lady Justice Thirlwall, who chaired the inquiry, said no-one at the hospital 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". She added that the "lack of consideration shown to parents" by hospital management was "reprehensible". The report found that senior nurses never accepted concerns from consultants about Letby were - or might be - justified and that there was a delay in senior management calling the police. Letby was found to have killed and harmed babies by injecting air into their blood, poisoning them with insulin, and overfeeding them with milk. Key Events Lucy Letby's lawyer issues fiery statement after two top experts quit hours before inquiry verdict Lucy Letby's lawyer has insisted her campaign for freedom has not been undermined after two key experts quit her defence team, warning that some of her legal arguments have "fundamental, unresolvable problems”. Engineering expert Helen Shannon and bioengineering professor Geoff Chase withdrew from the team on Monday, raising concerns about legal arguments put forward by Letby’s team. Video: Lady Justice Thirlwall recommends baby monitors on cots and incubators Lady Justice Thirlwall has recommended that all cots and incubators in all neonatal units should be fitted with in-cot cameras with livestreaming video to try and prevent anything like the events at the Countess of Chester Hospital ever happening again. Inquiry recommendations part 5 of 5: CQC assessment, ombudsman, implementation Lady Justice Thirlwall has made 17 recommendations in her report. - Assessment of the performance of CQC. There must be a rigorous and consistent review and assessment of the performance of CQC by the Health and Social Care Committee. - Parliamentary and Health Service Ombudsman. The functions of the National Guardian’s Office should be taken over by the Parliamentary and Health Service Ombudsman in England. The Ombudsman’s powers must be increased to include: investigating complaints that whistleblowing in the NHS has not been dealt with adequately and assisting whistleblowers by referring their concerns to the relevant NHS bodies. - Implementation of recommendations. Responsibility for auditing the implementation of the recommendations of statutory inquiries into NHS bodies should be given to the National Audit Office. Inquiry recommendations part 4 of 5: medical examiners, pathologists and accountability Lady Justice Thirlwall has made 17 recommendations in her report. - Medical examiners. There should be standardised national guidance on dealing with the death of a newborn. Medical examiners should ask direct questions of the attending practitioner as to whether there is a concern that a child has been harmed or some other safeguarding concern and record details of all medics who attended the baby. There should be a pool of neonatologists who can assist medical examiners until regional neonatologist medical examiners can be appointed. The medical examiner system should be reviewed again in 2027 by the government to see if there is enough funding. - Paediatric and perinatal pathologists. The government must ensure that by June 2033, there are 37 doctors in training posts as paediatric and perinatal pathologists - specialists in the death of children under one year old. - Accountability and regulation of managers. Health bosses need to put in place a barring system for all managers by 2027. New rules for senior managers moving between trusts to prove that the move is not proposed because of the manager’s lack of capability or misconduct and is a fit and proper person for the job. Managers must be subject to an individual duty of candour to all patients and colleagues. Guidelines for bosses must be changed to set out the duty of every manager to put patients first. - Care Quality Commission (CQC). The CQC should conduct without-notice inspections of hospital departments. Inspection teams should include at least two current practising experts in the relevant field. Inspectors should investigate what is happening in hospital departments and not accept what they are told at face value. Training should make explicit that CQC is responsible for ensuring the safety of patients in hospitals - inspectors must always approach an inspection of neonatal services not as a box-ticking exercise but as a way to determine that babies in hospital are safe. Inquiry recommendations part 3 of 5: sudden deaths, suspicion of harm, expert panel Here are the next set of recommendations Lady Justice Thirlwall made in her report. - Sudden Unexpected Death in Infancy and Childhood (SUDIC). NHS England must immediately inform all Trusts with a neonatal unit that the SUDIC process applies to the sudden and unexpected deaths of babies who have never left hospital. The government must complete its review and revision of the SUDIC guidelines and SUDIC forms must be redesigned and shortened to keep bureaucracy to a minimum. - Suspicion of Deliberate Harm Protocol and guidance. NHS England must set out the steps to be taken by managers when concerns or suspicions are raised that a healthcare professional may have deliberately harmed a patient. failure to follow the protocol will be a breach of contract by an employee, as well as a breach of the relevant code of conduct. The protocol muststress that it is irrelevant whether the person to whom the concerns have been expressed does or does not believe they are true, as is the fact that the person raising the concern is not sure. Only in cases where the concerns are obviously irrational or malicious (which assessment must be recorded) will no further action be justified. Pending investigation of a member of staff, action to protect patients by moving the person suspected of causing harm is likely to be the first step. The moving of a person suspected of causing harm and the investigation into suspicions and concerns about a member of staff is a neutral act. Safeguarding steps must be followed, as a result of which the police will become involved. - Panel of experts. The government should consider setting up a panel of independent experts including doctors, nurses, senior managers and pathologists to call upon when there are emerging concerns about an individual and harm to a patient or patients. This panel would conduct a swift, technical investigation into the concerns raised. In addition to reporting their findings to the Trust and government, the experts would be available to be called as witnesses in any proceedings that may follow. Inquiry recommendations part 2 of 5: operating systems, monitoring deaths, data reporting Lady Justice Thirlwall has made 17 recommendations in her report. - Operating systems (interoperability). NHS England must ensure computer systems are harmonised across the NHS by December 2028. The service must develop a mandatory information standard with systems that talk to each other so data relating to babies and neonates in hospital may be entered on a single occasion, be reviewed in a timely manner and facilitate continuous monitoring. - Monitoring deaths in hospitals. By 31 March 2027, all hospital Trusts must have in place effective mechanisms for Board-level monitoring of all deaths of children and babies as well as a clear and predetermined route to senior management for the escalation of concerning data trends or patterns. - Data reporting. All hospitals with a neonatal unit should name a ‘lead reporter’ with responsibility for inputting data regularly (at least weekly) and reviewing real-time data viewers on neonatal and maternity units. Where data requires immediate action a report should be made to the Medical Director and the Board immediately. The lead reporter should report to the Trust Boards at least every six months. Inquiry recommendations part 1 of 5: CCTV, Insulin monitoring and safeguarding Lady Justice Thirlwall has made 17 major recommendations in her report. Here are the first four: - CCTV and monitoring. All cots and incubators in all neonatal units should be fitted with baby monitors (in-cot cameras with livestreaming video), so that parents can observe their baby remotely at any time. The funding for this should be centrally managed and ring-fenced, to ensure consistency and implementation across all neonatal units at speed. By 31 March 2027, NHS England should set out a roadmap for how this will be implemented. - Insulin. Digital devices should be used to restrict access of insulin to authorised people and record access to insulin storage units. Until access to insulin requires the provision of biometric data, each Trust should install CCTV cameras focused on storage fridges, cupboards or units. - Bereavement care. The National Bereavement Care Pathway for neonatal death should be implemented nationally and in all Trusts by 31 August 2027. - Safeguarding and contracts of employment. Trusts must provide safeguarding training to all staff and Board members, including Non-Executive Directors.This training should include how to deal with concerns and suspicions about deliberate harm caused by staff. Every NHS hospital worker and agency staff must sign an obligation to follow all relevant safeguarding guidance, for dealing with concerns and suspicions about deliberate harm. 'Babies would have been saved and attacks prevented with earlier action' Our reporter Phil Cardy is at Liverpool Town Hall, where the Thirlwall Inquiry is reporting its findings. Inquiry chair Lady Justice Thirlwall said the collapse and deaths of some babies could have been avoided if safeguarding practices had been followed. Her report said "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 finds 'complete failure to protect babies' at Letby hospital Our reporter Phil Cardy is at Liverpool Town Hall, where the inquiry report has just been published. The Letby inquiry chair Lady Justice Thirlwall says there was a "complete failure to protect babies" at the Countess of Chester Hospital where Lucy Letby worked. She added that the "lack of consideration shown to parents" by hospital management was "reprehensible". 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." Inquiry report due to be published soon The Thirlwall Inquiry is due to report its findings at Liverpool Town Hall soon. The Mirror’s Phil Cardy is there and we will bring you the most important revelations as they happen. Criminal Cases Review Commission will be 'looking at report' The Criminal Cases Review Commission (CCRC) is currently considering a dossier of evidence submitted last year by experts on Lucy Letby’s behalf as part of her bid to challenge her convictions. The miscarriage of justice watchdog has also said it will look at today’s report. A CCRC spokesperson said: "We'll be looking at the report to assess whether it has a bearing on our review," according to Sky News. The CCRC is the organisation with the power to send Letby's case back to the Court of Appeal. Their review of her case is ongoing and no timeline has been set for when it may conclude. Recommendations by previous NHS inquiries were not followed As well as looking at the specifics of the issues around Letby’s crimes, the inquiry is also expected to expose the number of recommendations made by public inquiries into more than 30 previous NHS scandals, which have not been followed. Analysis by the inquiry's legal team showed that, of more than 1,400 recommendations made by previous healthcare-related inquiries, the majority have not been clearly implemented. Inquiry reviewed thousands of emails, texts and notes 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. 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. After months of hearings, including reviewing thousands of emails, text messages and handwritten notes, the findings of her inquiry will be published today, almost a year later than originally anticipated. Inquiry has not considered whether Letby is guilty or innocent The purpose of the Inquiry has not been to consider the convictions of Lucy Letby. Rather, it takes the background of her convictions as the starting point, bosses have said. Lady Justice Thirlwall said she had "approached the inquiry on the basis that Lucy Letby is guilty of the crimes of which she has been convicted". Letby received 15 whole-life orders after two trials at Manchester crown court. She was convicted of murdering seven babies and attempting to murder seven others, with two attempts on one of her victims. She is currently attempting to challenge her convictions. The Criminal Cases Review Commission (CCRC), the UK's miscarriage of justice watchdog, is considering a dossier of evidence submitted last year by experts on her behalf. It is vital that lessons are learned - families The families of Letby’s victims have been waiting years for answers. They have said that the government must fully implement the recommendations of the inquiry into the killer nurse. Specialist medical negligence lawyers at Irwin Mitchell, representing seven children harmed by Lucy Letby, said the publication of the inquiry’s findings will be an important and difficult moment for everyone affected. Tamlin Bolton, from Irwin Mitchell, said: "The publication of the Thirlwall Inquiry’s findings will likely be difficult reading for our clients and for everyone affected by Lucy Letby’s actions who have already had to go through both a criminal trial and several months of evidence for this Inquiry. "For the families we represent, this Inquiry has always been about understanding how these devastating events were able to happen and ensuring that meaningful lessons are learned. “While no system can guarantee the prevention of criminal acts by a determined individual, patients, families and clinicians are entitled to expect that their concerns will be listened to and that those concerns will be investigated properly and acted upon." She added: "The key questions are whether the systems, culture and governance within our NHS were sufficiently robust to identify risks and respond to them appropriately and where, in this instance, those systems have failed. "With the families, we will consider Lady Justice Thirlwall's findings carefully, but whatever the detail of the report, it is vital that lessons are learned and any recommendations are implemented by the UK Government so that confidence in patient safety is strengthened. "Families need to have confidence that everything possible is being done to prevent similar failings happening again, whether in Chester or elsewhere in the NHS." Inquiry to highlight 'missed opportunities' The inquiry is expected to highlight a number of missed opportunities for bosses to intervene after doctors raised the alarm about a spate of unexplained baby deaths on the neonatal unit where Letby worked. A criminal investigation into three hospital executives is still underway by Cheshire Police. They were previously arrested on suspicion of gross negligence manslaughter and one has since been rearrested on suspicion of perverting the course of justice. What will the inquiry look at? The final report from the Thirlwall Inquiry, which has examined how serial killer Lucy Letby was able to commit her crimes on a hospital neonatal unit, is set to be released today. The inquiry heard evidence on events at the Countess of Chester hospital's neonatal unit where Letby was a nurse between 2015 and 2016. Consultants repeatedly raised concerns that Letby, now 36, may have been behind a series of unexplained deaths before she was arrested. Letby is serving 15 whole-life orders after she was convicted of murdering seven babies and attempting to murder seven others, with two attempts on one of her victims. One of the core aims of the Inquiry, set up in September 2023, was to consider how an NHS Trust responds to, reacts and treats concerns raised by staff of serious criminal actions in its own hospital.