LUCY LETBY WAS ALLOWED TO KEEP HARMING BABIES — NOW A MAJOR INQUIRY HAS REVEALED WHAT WENT WRONG

A two-year public inquiry has found profound failures in management, safeguarding and leadership at the hospital where Lucy Letby was convicted of murdering seven babies and attempting to murder seven others.

For years, questions have surrounded how Letby was able to remain working in the neonatal unit while concerns about the deaths and collapses of babies were emerging.

Now, the long-awaited Thirlwall Inquiry report, published on September 15, 2026, has delivered a damning assessment of the hospital’s response.

The inquiry found that some babies could have been saved and others could have been protected if action had been taken earlier.

WARNINGS WERE NOT ACTED ON

The inquiry found a serious breakdown between hospital leadership and clinicians.

Senior doctors raised concerns about what was happening on the neonatal unit, but senior nursing leaders did not accept that those concerns might be justified.

Instead of immediately treating the possibility of deliberate harm as a safeguarding issue, the hospital delayed action.

The inquiry also found a prolonged delay in contacting police.

Doctors who raised concerns were themselves subjected to scrutiny, while plans were even considered to return Letby to the neonatal unit before those plans were eventually abandoned.

Lady Justice Kathryn Thirlwall described the situation as a “complete failure to protect babies.”

FAMILIES WERE KEPT IN THE DARK

One of the most painful findings concerned the parents.

According to the inquiry, families were not told for years that concerns existed about the possibility that their babies may have been deliberately harmed.

Parents were also not informed about certain reviews or asked for consent before their children’s medical records were shared with outside experts and organisations.

The inquiry described the lack of consideration shown to parents as “reprehensible.”

HOW MANY BABIES COULD HAVE BEEN SAVED?

The inquiry concluded that at least some of the deaths and attacks could have been prevented if concerns had been acted upon sooner.

The Guardian reported that the inquiry found three babies may have survived and seven others could have been protected had hospital leaders and doctors acted earlier.

The exact circumstances surrounding each baby’s death remain subject to the criminal proceedings, reporting restrictions and continuing legal processes.

 17 RECOMMENDATIONS FOR THE NHS

The inquiry has called for major changes to neonatal care and safeguarding.

Among its 17 recommendations are proposals for:

• Cameras with livestreaming capability in neonatal cots and incubators
• Stronger controls over access to insulin
• CCTV around insulin storage until biometric controls are introduced
• Board-level monitoring of deaths involving babies and children
• A national NHS protocol for situations in which a member of staff is suspected of deliberately harming a patient

The goal is to ensure that suspicion of deliberate harm is treated as a safeguarding concern rather than something that requires colleagues to first establish guilt.

WHAT THIS REPORT DOES — AND DOES NOT — CHANGE

Lucy Letby was convicted in 2023 of murdering seven babies and attempting to murder seven others and is serving life sentences.

However, the Thirlwall Inquiry was not an appeal and did not reconsider her convictions.

Letby’s legal team continues to maintain her innocence, and the Criminal Cases Review Commission is considering her case. The inquiry itself proceeded on the basis of the convictions and focused on how the hospital responded to concerns surrounding the babies.

That distinction is crucial.

The report has exposed major institutional failures — but those findings do not, by themselves, overturn the criminal convictions.

A SYSTEM THAT FAILED TO RESPOND

The final report leaves a devastating picture of a hospital where warnings were not acted upon quickly enough, doctors and managers became divided, and parents were left without crucial information.

Its central message is unmistakable: when a member of staff is suspected of deliberately harming patients, safeguarding action cannot wait for certainty.

The inquiry now calls for the NHS to change how such warnings are handled — with the hope that what happened at the Countess of Chester Hospital will never happen again.

The full story behind the inquiry’s most shocking findings is only beginning to emerge.