Lucy Letby inquiry exposes ‘shocking’ NHS failings and calls for major changes to protect babies

The Thirlwall Inquiry into Lucy Letby has exposed serious NHS failings and set out 17 recommendations to improve patient safety.

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Published: September 15, 2026 at 12:42 PM

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The public inquiry examining events surrounding Lucy Letby at the Countess of Chester Hospital has published its findings, describing a “dispiriting and at times shocking account of multiple and repeated mistakes and failings by organisations and individuals”.

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The Thirlwall Inquiry was established following the convictions of former neonatal nurse Lucy Letby. Its report examines events at the hospital between 2015 and 2018, including how concerns were handled, the experiences of the babies' parents and wider issues around NHS management, safeguarding and patient safety.

Importantly, Lady Justice Thirlwall makes clear that the Inquiry's focus was not on Lucy Letby's guilt or her convictions. Instead, it investigated what happened at the hospital and what needs to change. For parents, its findings raise serious questions about how the NHS responds when staff fear babies or children may be at risk.

Lucy Letby inquiry reveals serious NHS failings

The Thirlwall Inquiry is highly critical of the way concerns surrounding Lucy Letby were handled at the Countess of Chester Hospital, finding repeated missed opportunities to put the safety of babies first.

Concerns had been developing as the neonatal unit experienced an unusual increase in deaths. In May 2016, consultant paediatrician Dr Stephen Brearey raised concerns with senior managers that the increase in neonatal mortality could be linked to Letby. The Inquiry found those present understood his concern could mean either incompetence or deliberate harm.

But the outcome of a key meeting on 11 May was to “monitor and alert”. Lady Justice Thirlwall found that Dr Brearey's concerns had been “shouted down by the nurses and ignored by the executives”. Letby continued working on the neonatal unit.

By 29 June 2016, consultant paediatricians were explicitly raising concerns about deliberate harm. The Executive Team discussed involving the police and even closing the unit, but no safeguarding procedures were started. Meeting notes recorded then-chief executive Tony Chambers asking, “can we explore more [before] police?”

The following day, the hospital decided to downgrade the neonatal unit and commission an external review by the Royal College of Paediatrics and Child Health (RCPCH). Contacting the police was not part of that plan. Lady Justice Thirlwall concluded: “It should have been. No steps were taken to protect babies.”

Safeguarding concerns about Lucy Letby were not acted on

The Inquiry found a fundamental failure to recognise concerns that a member of staff might be deliberately harming babies as a safeguarding issue.

Safeguarding training at the hospital did not cover the possibility of a member of staff harming children, something the Inquiry calls a “very significant omission”. It found that staff did not understand that suspicion or concern was enough to trigger safeguarding action, without needing proof that deliberate harm had taken place.

Alison Kelly, then Director of Nursing and Quality and the hospital's Executive Lead for Safeguarding, and Medical Director Ian Harvey had known about concerns surrounding Letby since May 2016. The Inquiry found both believed the doctors were wrong.

Lady Justice Thirlwall concluded that their focus was on finding other explanations for the deaths, rather than asking how babies could be protected. A safeguarding referral was not made until March 2018.

The Inquiry was also critical of the failure to tell outside NHS bodies the full extent of what doctors were saying. In July 2016, senior figures from the hospital met NHS England and commissioning representatives and discussed neonatal mortality, safeguarding and the possibility of police involvement. But the consultants' concerns about deliberate harm were not disclosed and no safeguarding or police referral was made.

The hospital's risk systems failed to protect babies

The report also finds that the hospital's Risk and Patient Safety Department “failed in its fundamental task to enhance patient safety”.

Despite eight babies dying on the neonatal unit in 2015 and another five deaths by the end of June 2016, neonatal deaths were not entered onto a risk register until 11 July 2016. The Inquiry found the hospital's risk systems and processes had failed in their “principal purpose of protecting patients, here the babies on the neonatal unit”.

One Executive Risk Register entry focused on the “Potential damage to Reputation of Neonatal Service and Wider Trust due to Apparent Increased Mortality within the Neonatal Unit”. The Inquiry notes that this reputational risk was scored 20 out of 25, while a separate risk concerning neonatal mortality was scored 15.

Patient safety became secondary to an HR process

Another major criticism concerns what happened after Lucy Letby raised a grievance in September 2016.

The Inquiry found senior managers failed to deal “openly and honestly with the serious risk posed by Letby to patient safety”. It also found that the people appointed to deal with the grievance lacked the appropriate independence, skills or experience for a case of such seriousness and complexity.

The Inquiry's wider conclusion is stark: in 2016, “patient safety and safeguarding concerns were relegated below a flawed HR investigation of Letby’s grievance. This was wrong.”

Lady Justice Thirlwall says that when NHS employers are weighing the risk of an employment claim against a genuine concern for patient safety, protecting patients must come first.

The starting point for everyone must be patient safety. It must be the top priority for all managers.

Lady Justice Thirlwall

The police investigation was ultimately opened in May 2017. The Inquiry concludes: “The police should have been notified earlier than they were.”

Missed opportunities to protect babies from further harm

The Thirlwall Inquiry does not make a blanket finding that all the deaths could have been prevented. But it identifies a series of opportunities when concerns surrounding Lucy Letby could have been investigated and action taken much sooner.

The first came after Baby A died suddenly and unexpectedly on 8 June 2015. Lady Justice Thirlwall found that the Sudden Unexpected Death in Infancy and Childhood, or SUDIC, process should have been triggered following Baby A's death. That would have resulted in an “independent and systematic investigation”, involving the local authority and police. The same process should subsequently have been followed after the deaths of Babies C, D, E, I, O and P.

By May 2016, senior hospital managers were aware of concerns surrounding Lucy Letby. Yet safeguarding procedures were not followed. The Inquiry found that Alison Kelly and Ian Harvey knew the doctors' concerns were genuine, but believed they were wrong. Lady Justice Thirlwall concluded that their focus was on finding other possible causes of the deaths rather than asking “how can babies be protected”.

Letby remained on the neonatal unit. Babies O and P, two triplet brothers who had been born in good condition, died on consecutive days on 23 and 24 June 2016. Letby was later convicted of murdering both babies.

It was only after Baby P's death that the hospital's previous “wait and see/monitor and alert” approach ended. Even then, the Inquiry found that an initial plan would have allowed Letby to continue working day shifts with patients, prompting Dr Brearey to express disbelief that she could continue to have contact with babies despite the paediatricians' concerns about their safety.

Letby was eventually moved into a non-clinical role in July 2016. The Inquiry notes that there has been one death on the neonatal unit since July 2016, which occurred in September 2019.

The Inquiry also records how these missed opportunities have affected the families. Baby Q suffered an unexpected collapse on 25 June 2016. Letby was charged with his attempted murder, although the jury was unable to reach a verdict on that charge. Mother Q told the Inquiry about her belief that what happened to her son could have been avoided had Letby been stopped earlier.

One thing that I really struggle with is, this had been going on for such a long time and Child Q was the last one if she would have been caught before, this wouldn’t have happened to Child Q.

Mother Q

The Inquiry's findings underpin one of its most significant recommendations: when concerns that a healthcare professional may be deliberately harming patients are raised in good faith, they must be acted on immediately, even if the person receiving the warning does not believe them or the person raising them is unsure.

What changes has the Thirlwall Inquiry recommended?

The Lucy Letby inquiry has made 17 recommendations, with proposed changes stretching from neonatal units to NHS boardrooms and the Care Quality Commission (CQC).

They include:

New safeguarding rules following the Lucy Letby inquiry

One of the most significant recommendations concerns what NHS managers should do when someone raises concerns that a healthcare professional may be deliberately harming patients.

The Inquiry wants NHS England to produce a one-page Suspicion of Deliberate Harm Protocol by 31 March 2027.

The proposed protocol says concerns raised in good faith must be acted on immediately, regardless of whether the manager receiving them believes they are true or whether the person raising them is certain. Only concerns assessed as “obviously irrational or malicious” would justify taking no further action, and that assessment would have to be recorded.

Protecting patients by moving the staff member suspected of causing harm is likely to be the first step while an investigation takes place, according to the recommendations. Safeguarding procedures should then be followed, resulting in police involvement.

Parents could remotely see babies in neonatal care

For families, one particularly notable recommendation is the proposed introduction of cameras for babies receiving neonatal care.

Lady Justice Thirlwall recommends that every cot and incubator in neonatal units should have a baby monitor with livestreaming video, allowing parents to observe their baby remotely “at any time”.

Funding should be centrally managed and ring-fenced, with NHS England asked to publish a roadmap by 31 March 2027 explaining how the system would be introduced.

The recommendation does not mean cameras will immediately be installed in every neonatal unit, but sets out what the Inquiry believes should happen next.

NHS managers could face tougher accountability

The Thirlwall Inquiry also recommends substantial changes to the accountability of NHS managers following its examination of the response to concerns surrounding Lucy Letby.

It calls for the Department of Health and Social Care and NHS England to establish a barring system for all clinical and non-clinical managers by September 2027. This should be reviewed in 2030 with a view to moving to full statutory regulation by September 2032.

Managers should also be subject to an individual duty of candour to patients and colleagues.

The Inquiry recommends that the NHS managers' code should begin with an explicit duty to put patients first. Lady Justice Thirlwall suggests the wording:

I will make the care and safety of patients my first concern and act to protect them from risk.

Lady Justice Thirlwall's suggested wording for the NHS managers' code

What happens after the Lucy Letby inquiry?

Many of the 17 recommendations come with deadlines during 2027, but they are recommendations rather than confirmation that every proposed change is already NHS policy.

The Inquiry has also addressed the problem of recommendations from previous NHS inquiries not necessarily translating into lasting change. It recommends giving the National Audit Office responsibility for auditing the implementation of recommendations from statutory inquiries into NHS bodies, with funding for additional staff so that work can begin by September 2027.

For families, the focus now turns to whether the lessons identified by the Thirlwall Inquiry lead to lasting changes in how babies and children are protected across the NHS.

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Authors

Ruairidh PritchardDigital Growth Lead

Ruairidh is the Digital Lead on MadeForMums. He works with a team of fantastically talented content creators and subject-matter experts on MadeForMums.

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