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The Thirlwall inquiry report examines how the Countess of Chester hospital responded to the deaths and collapses of babies linked to Lucy Letby. It does not assess whether Letby is guilty, but the Criminal Cases Review Commission will consider whether its findings affect her case review.
The Thirlwall report into events at the Countess of Chester hospital linked to Lucy Letby's convictions for murdering and attempting to murder babies is being published today.
It follows public and private hearings examining the hospital's conduct, the experiences of parents and the wider NHS systems intended to protect babies in care. The report is not intended to decide whether Letby committed the offences for which she was convicted. The inquiry was conducted entirely on the basis that she was guilty of those offences, and it will not express a view on the safety of her convictions or on her guilt.
Letby was sentenced at Manchester crown court on August 21st, 2023, to life imprisonment with a whole-life order. She had been convicted of seven counts of murder and six counts of attempted murder. She was later convicted at a retrial of a seventh attempted murder. All attempts by Letby to appeal against the convictions were dismissed, although her case remains under review by the Criminal Cases Review Commission, known as the CCRC.
The CCRC is investigating whether there is a real possibility that Letby's convictions would not be upheld. If the review reaches that conclusion, it could lead to a referral back to the appeal courts. The Thirlwall inquiry was announced as an independent public inquiry on September 4th, 2023. Its purpose was to provide answers for the families of the victims and ensure that lessons were learned from what happened at the Countess of Chester hospital.
The inquiry also examined the wider response and conduct of the National Health Service, its staff and its regulators. Its work was not limited to the actions of Letby, but considered how concerns were handled and whether institutional failures allowed risks to continue. One main area was the experience of parents.
The inquiry examined what information parents were given about their babies' care, sudden deteriorations and safety concerns, as well as whether the hospital was candid with families about what was happening. A second area concerned hospital conduct and governance. The investigation covered the hospital's operations from Letby's arrival on January 4th, 2012 onwards, including when concerns were raised and how managers responded to them.
It also considered the treatment of whistleblowers, delays in reporting concerns to the police and regulatory bodies, and possible failures in the hospital's internal governance. These issues were examined alongside the events surrounding the babies named in the criminal indictment. The third area was the wider NHS framework. The inquiry assessed whether NHS management structures, executive accountability, regulation and hospital culture were capable of protecting babies in care settings and responding effectively when warning signs emerged.
The inquiry is chaired by Lady Justice Thirlwall, a senior Court of Appeal judge. Rachel Langdale is counsel to the inquiry. She was leading counsel for a core participant in the Mid-Staffordshire NHS Foundation Trust public inquiry and has acted for local authorities and individuals in inquiries involving safeguarding and children in care. The core participants included the families of the children named on the indictment, who were represented by legal teams.
Other participants included the Royal College of Paediatrics and Child Health, the Department of Health and Social Care, the Countess of Chester Hospital NHS Foundation Trust, the Nursing and Midwifery Council, the Care Quality Commission and NHS England. The report could nevertheless have implications for the continuing review of Letby's case. The chair of the CCRC told the BBC that the miscarriages of justice watchdog would examine the conclusions reached by the Thirlwall inquiry.
She said the CCRC would look at the report with interest to assess whether it had any bearing on its review of the case. The watchdog can use material, evidence and findings gathered by a public inquiry when considering whether a conviction or sentence might be unsafe. That does not mean the report itself overturns any conviction or changes Letby's sentence.
Any decision to refer the case back to the appeal courts would rest with the CCRC after it completes its review of the available evidence and legal issues. The publication comes after months of evidence and testimony about the hospital's handling of concerns, its dealings with parents and the responsibilities of NHS leaders and regulators. The findings are expected to address both the immediate events at the Countess of Chester and broader questions about accountability in neonatal care.
For the families involved, the inquiry was established to provide a fuller account of what happened and why concerns were not acted on sooner. Its conclusions may also shape recommendations for hospitals, regulators and NHS organisations responsible for the safety of babies and the treatment of parents. The report therefore has two distinct roles. It records and assesses the institutional circumstances surrounding the cases, while the criminal convictions remain matters for the courts and the CCRC review. The inquiry's findings are not a fresh criminal verdict on Letby.
Thirlwall Inquiry Countess Of Chester Hospital Criminal Cases Review Commission NHS Governance
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