A public inquiry has found a “complete failure at all levels” to protect babies at the Countess of Chester Hospital, where neonatal nurse Lucy Letby was convicted of murdering seven newborns.
Justice Kathryn Thirlwall said dysfunctional management and delays in responding to babies’ collapses meant some infants could have been saved and attacks prevented.
“Errors were made by nurses, doctors and managers,” she said. “There was also complete failure at all levels to invoke safeguarding procedures at any point.”
The inquiry did not examine Letby’s convictions. Instead, it considered how institutional failures allowed babies to be repeatedly harmed, how hospital staff and managers responded, and how parents were treated.
Justice Thirlwall said the hospital failed to intervene when it became clear that someone was deliberately harming babies. “How many lives could have been saved had the hospital acted differently?” she asked.
“It is clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier,” she said.
Letby, 36, is serving a life sentence after being convicted in 2023 of murdering seven infants and attempting to kill six others, including two attempts on one child. A further retrial ended with her conviction in July for another attempted murder.
She was sentenced to 15 life terms with no chance of release, becoming only the fourth woman in the United Kingdom to receive such a sentence.
Prosecutors said Letby harmed babies in ways that left little trace, including injecting air into their bloodstreams, putting air or milk into their stomachs through nasogastric tubes, poisoning them with insulin and interfering with breathing tubes.
She was the only employee on duty in the neonatal unit when the children collapsed or died between June 2015 and June 2016. Prosecutors described her as a “constant malevolent presence”.
Letby has maintained her innocence. A defence team supported by dozens of scientists who have questioned the evidence against her is seeking to clear her name.
