Summary
The Thirlwall Public Inquiry found that doctors’ concerns about Lucy Letby were dismissed at the Countess of Chester Hospital and that earlier police involvement might have saved some babies. It recommended tighter neonatal monitoring, insulin-access controls and a barring system for NHS managers dismissed for serious misconduct.
The Thirlwall Public Inquiry has found that failures at the Countess of Chester Hospital allowed concerns about Lucy Letby to be dismissed and concluded that some babies who died could have been saved if police had been notified earlier. The inquiry’s report, published on 15 September 2026, sets out 17 recommendations covering neonatal safety, insulin access and accountability for NHS managers.
Letby is serving a life sentence after being convicted of murdering seven babies and attempting to murder seven others between June 2015 and June 2016.
How concerns were handled at the hospital
The inquiry found that hospital staff did not understand that the Sudden Unexpected Death in Infancy and Childhood protocol, known as SUDIC, also applied to babies who died in hospital. Had the protocol been followed, police would have been called after the death of Baby A in June 2015. The inquiry said that this would have led to an independent and systemic investigation involving the police and local authority. The same process should have followed the deaths of six other babies, it found. Police were eventually notified in May 2017.
The report also found that consultants’ growing suspicions were not treated as a safeguarding concern. Instead, senior management focused on protecting the hospital’s reputation and redirected the board away from the possibility of criminal acts. Inquiry chair Lady Justice Thirlwall described the result as dysfunctional management and governance, a divide between hospital leadership and clinicians, and a failure to understand basic safeguarding responsibilities.
A key finding was that action to protect babies should begin when a staff member is suspected of causing deliberate harm; colleagues do not need to be certain that the person is guilty before safeguarding measures are taken.
The inquiry found that senior nurses showed unquestioning loyalty to Letby and that professional “tribalism” contributed to the breakdown between nurses and doctors raising concerns. Letby was moved from the neonatal unit to administrative duties in July 2016. After she submitted a grievance, chief executive Tony Chambers agreed to allow her to return to the unit in April 2017, although opposition from consultants prevented that return. The inquiry found that two consultants, Stephen Brearey and Ravi Jayaram, were made to apologise to Letby and threatened with referral to the General Medical Council.
Proposed changes to neonatal safety and NHS management
The inquiry recommended video monitors, or “cot cams”, in neonatal settings so that parents can observe their babies at any time. It also called for stronger guidance on the safe use and storage of insulin, along with digital systems that restrict access to authorised personnel and record access to storage areas.
The report said all neonatal units should use biometric controls for insulin access by 31 March 2027. Until then, NHS trusts should install closed-circuit television cameras covering insulin storage fridges, cupboards or units.
A separate recommendation calls for a national barring system for clinical and non-clinical NHS managers dismissed for serious misconduct. The Department of Health and Social Care and NHS England are expected to establish that system by September 2027, preventing individuals removed for serious misconduct from moving into other NHS roles.
The inquiry also recommended stronger guidance for medical examiners who review neonatal deaths. The government has pledged urgent action on these measures while it considers the full set of recommendations, and the Department of Health and Social Care is setting up a hub to track how recommendations from NHS inquiries are implemented.
NHS England’s chief nursing officer, Duncan Burton, issued an apology to the affected families and acknowledged failures by the organisation to challenge the hospital trust’s assurances and delays in its investigations. Separately, Cheshire Police is investigating possible corporate manslaughter at the hospital; the inquiry report notes that the investigation was widened in 2025 and that former senior managers remain on bail.
Letby is pursuing a further route through the Criminal Cases Review Commission after two unsuccessful attempts to appeal her convictions. The inquiry’s recommendations now place the emphasis on earlier safeguarding action, traceable access to high-risk medicines and greater accountability for NHS leadership.