Thirlwall: Guilty or not there was ‘total failure of safeguarding’ at Letby trust

Lady Thirlwall has rejected calls from senior managers to pause the official inquiry into the deaths of infants at the Countess of Chester Hospital.

On the last day of hearings yesterday, she said — regardless of the outcome of a referral to the Criminal Cases Review Commission by Lucy Letby’s legal team — her final report would highlight “a total failure of safeguarding at every level”.

The neonatal nurse was convicted of the murder of seven babies and the attempted murder of others at two trials in 2023 and 2024. Appeals were rejected.

Lady Thirlwall’s inquiry was tasked with looking at three things: the experience of families at the trust, whether suspicions should have been raised earlier and the police called, and the effectiveness of governance and processes.

The legal team representing the former chief executive, nursing director, medical director, and HR director wrote to the inquiry last month to argue that the new evidence produced by Letby’s lawyers and the possibility of the convictions being overturned undermined the basis of the inquiry.

Lady Thirlwall said at the start of the inquiry that she had dismissed doubts about the safety of Letby’s conviction as “noise”.

She added: “The inquiry has been conspicuously fair. [It] does not become unfair because there is a possibility that all the convictions are unsafe. I completely accept and have approached the inquiry in this way; [that] it is essential to guard against hindsight in covering the actions of people eight, nine, and 10 years ago…

“It is not the actions of Lucy Letby I am scrutinising, it is the actions of the people in the hospital, what they knew and should have known at the time.

“There are already large numbers of concessions about what wasn’t done that should have been done [at] the organisations, the hospital, including the doctors and the managers. And that managers should have communicated better with patients and provided pastoral care to the doctors.”

She noted an “acknowledgement that there was a total failure of safeguarding at every level and that will not change. Inevitably [that] will feature in any report.”

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Source: HSJ, 19 March 2025