Erica Witherington
Reporting from Liverpool

While delivering her statement, Lady Justice Thirlwall pointed out findings about specific staff members at the Countess of Chester hospital.

Thirlwall said that ‘from the outset”, director of nursing and head of safeguarding Alison Kelly and medical director Ian Harvey “dismissed the idea that Letby was deliberately harming babies".

“They did not believe it,” she said, pointing out that when hospital chief executive Tony Chambers became aware of what was happening on the unit - only after the deaths of the two final babies in this case, babies O and P in June 2016 - he did not believe it was Letby either.

But Thirlwall said whether these managers believed Letby was harming babies or not was “irrelevant”.

She said they should have taken action.

Thirlwall highlighted a remark that Chambers made in his first meeting with the consultants who were concerned that Letby might be attacking babies: “That would be convenient,” she said that he said.

Thirlwall called this “offensive”, and said he added to the “unnecessary delay” in calling the police.

Nick Triggle
Health correspondent

Image source, Getty Images

The failings at the Countess of Chester Hospital were not just down to one organisation and its staff, the inquiry made clear - the culture of the NHS played a part too.

It said there was a tendency across NHS management to become preoccupied with avoiding blame and focusing on reputation management - something that was apparent in the approach over Letby.

And despite attempts over the last 10 years to bring in protections for whistleblowing, there was still evidence of a "toxic negativity" that discouraged people working in the NHS to speak out.

Regulation was also found lacking. The Care Quality Commission (CQC) inspected the Countess of Chester in February 2016 - Letby carried on attacking babies until June of that year. Key information was withheld from inspectors, but the regulator was criticised for not showing enough curiosity to look beyond what they were being told.

What makes this worse is that only a year before, the CQC had been warned by the inquiry into baby deaths at Morecambe Bay NHS Trust that it needed to take a tougher approach.

This report extends the footprint of blame around babies' deathspublished at 13:15 BST

13:15 BST

Judith Moritz
Reporting from Liverpool

The question of whether babies might have lived or avoided injury was always going to be the starkest issue for Lady Justice Thirlwall to resolve.

She is firm in her view that some of Letby’s murders and attacks could have been prevented, but has held back from specifying exactly how many babies might have been saved. She says that "this is something we will never know for sure”.

According to Thirlwall’s timeline, if action had been taken after the unusual cluster of three deaths in June 2015, it might have prevented another four babies from being killed.

If something had been done in October 2015 it would have stopped three of the deaths. There are other missed opportunities identified in February 2016 and May 2016 before the deaths of two triplet brothers happened in June 2016.

Seeing this litany of missed opportunities set out so clearly in black and white makes for alarming reading.

The babies’ parents have been poring over the report this morning - and are firm in their view that Lucy Letby could have been stopped long before she was eventually removed from nursing.

They are in no doubt of her guilt, and the Thirlwall Inquiry has operated on the same basis, its chair writing that “the avenues of appeal for convicted persons are well known and they do not include a public inquiry”.

The sound of Letby’s supporters protesting on the pavement outside is audible within the hearing room.

They will scour the Thirlwall report for evidence that it has exposed a chaotic hospital with widespread failings, and a nurse who has been scapegoated.

But it will also be read keenly by those who do not doubt Letby’s criminality - and who now have the wider context of what managers failed to do to stop her.

It’s those managers who will likely emerge most bruised from this inquiry. Lady Justice Thirlwall has not pulled her punches, finding that between them they were dictatorial, ran an exercise in spin, tried to control the narrative, and lost all judgement.

Only Lucy Letby has been held criminally responsible for the babies’ deaths and near-deaths, but this report extends the footprint of blame.

Thirlwall finishes by repeating her thanks to the parents for "generously and thoughtfully" contributing to the inquiry.

"They have borne this exercise with dignity and fortitude," she notes.

Thirlwall says she hopes the parents' evidence, along with the inquiry's recommendations, will mean "others do not have to live through experiences like theirs".

We'll continue to unpack the report and bring you analysis.

Back now to Lady Justice Thirlwall, who is delivering her statement.

She is continuing to outline recommendations, which include:

• Compulsory training on safeguarding for all staff including board members for how to deal with concerns and suspicions about "deliberate harm caused by staff"
• The training will require employees to raise concerns and "achieve a cultural shift", reducing the burden on freedom-to-speak-up guardians
• She next says new guidelines on sudden unexpected death in infancy and childhood (SUDIC) should be distributed no later than 31 March next year
• She recommends board level monitoring for the deaths of all children and babies with a clear route to the board for escalation of concerning data trends or patterns
• "Deaths of babies should never again go unnoticed by the board of a hospital," she says
• On hospital managers, she says that they should owe an "individual duty of candour" to all patients, colleagues and external agencies
• Inspections of neonatal units should also be upgraded to be more "effective"

The recommendations are to prevent the "revolving door" in the NHS, which she describes as "the movement of senior managers between trusts without accountability".

Thirlwall calls for an "energetic and determined" approach to putting her recommendations into place.

We can now bring you reaction from Richard Scorer, head of abuse law and public inquiries at Slater and Gordon, who acts for three of the affected families.

"The families I represent were looking for a clear analysis of what went wrong and strong recommendations to prevent this happening again," he says.

"The report delivers both. Lady Thirlwall is clear that the police should have been informed in August 2015, not 18 months later, and that hospital managers misled the families and the trust failed in its duty of candour."

Scorer adds: "My clients welcome the recommendations around CCTV, access to insulin, strengthening of the duty of candour to include hospital managers and barring of managers guilty of incompetence and misconduct.

"The challenge now is to ensure that recommendations are implemented without delay. Far too often public inquiry recommendations are left to gather dust.

"This cannot be allowed to happen again."

We're continuing to bring you lines from Lady Justice Thirlwall, who is delivering a statement following the release of the report.

She just reminded listeners that this was not an investigation into Lucy Letby's guilt.

Letby is serving 15 whole-life prison terms for murdering seven babies and attempting to murder seven others, including one baby whom she tried to murder twice.

• This post contains distressing details

Thirlwall speaks to the experiences of some of the parents and the "important" information they could have imparted on any investigation.

For example, she says one mother had information to give if she was asked. She had "heard her baby screaming and saw that he had blood on his mouth".

"Letby was there."

She says the collapses and deaths continued after multiple missed opportunities to act.

Thirlwall now outlines her recommendations.

She says all cots and incubators in all neonatal units should be fitted with video baby monitors so that parents can observe their baby remotely at any time.

This will deter someone who wants to harm a baby and should happen within 12 months, she adds.

Thirlwall also recommends implementing requirements for the access, control and storage of insulin.

She also calls for new protocols to be taken when suspicions of harm have been raised, adding: "Never again should any manager assert that they did not know what to do."

The anger some parents feel at the way they were treated by the Countess of Chester Hospital was "palpable", Lady Justice Thirlwall says.

She adds that parents were "kept in the dark for years" about what was happening - about the fact that there were concerns their babies may have been deliberately harmed.

"Their consent was not obtained for sharing their babies’ medical records with external experts and other organisations", Thirlwall notes, adding that the parents were not informed about reviews.

Only in 2018 they learned that the collapses and deaths may have been the result of the actions of a nurse whom they had trusted, she says.

"The lack of consideration shown to the parents at that time was reprehensible," Thirlwall says.

Thirlwall says the identities of babies on the indictment and their families cannot be named, because of court orders.

She urges "everyone commenting on the events" at the hospital to "remind themselves that these are all real people who have suffered grievously".

Their "dignity and courage should be respected by everyone", she says.

Almost all of the parents gave evidence to the inquiry - which is available on its website - and people should "keep their evidence in mind", Thirlwall says.

"The families must not become collateral damage in the public argument about whether or not Letby is guilty."

Thirlwall goes on to say the hospital was "far adrift" from the correct course of a prompt response to serious concerns raised by consultants about the safety of babies by the beginning of 2017.

She adds the report is not an investigation into the guilt of Letby, adding that those avenues have not and do not include this public inquiry.

Thirlwall says her principal focus in her inquiry has been on three broad topics:

• What was known by whom at the time about the collapses and/or deaths of babies in the neonatal unit
• The role of external organisations including the Care Quality Commission, NHS England and the Royal College of Paediatrics and Child Health
• The wider NHS, and how the accountability of managers should be improved

We are now turning to the chair of the inquiry, Lady Justice Thirlwall, who is delivering a statement. You can watch live above.

She says the inquiry was set up on 19 October, 2023, after Lucy Letby was convicted.

She says the report describes "dysfunctional management and governance", and a failure to understand the fundamentals of safeguarding.

Thirlwall says errors were made by nurses, doctors and managers, and while looking for clinical and other explanations for deaths wasn't wrong, safeguarding steps should have been taken once there was suspicion that Letby may have been causing harm deliberately.

Letby should have been removed from the ward as a neutral act while the deaths were investigated, she adds.

From the death of baby P in late June 2016, and despite fact Letby had been removed from neonatal unit, there was a long delay in reporting to police, who were eventually contacted in May 2017, she says.

Judith Moritz and Lauren Hirst
Reporting from Liverpool

We are shortly going to be moving to reporting on remarks from inquiry chair Lady Justice Thirlwall, who is delivering a statement.

Before then, here's a summary of the report's key findings:

• The deaths and near-deaths of some babies who were attacked by nurse Lucy Letby could have been prevented if safeguarding practices had been followed
• The inquiry chair Lady Justice Thirlwall says it will never be possible to know for sure how many lives could have been saved, but has found there was a “complete failure to protect babies on the neonatal unit” at the Countess of Chester Hospital
• Thirlwall says “this must never happen again” as she calls for a “series of urgent reforms to practices” in neonatal units
• She highlights a “profound failure of management, governance and safeguarding”
• She describes a “dysfunctional management and governance, a gulf between hospital leadership and clinicians and a failure to understand the fundamentals of safeguarding”

We can bring you more now from the inquiry.

The failings at the Countess of Chester were not just down to one organisation and its staff, the inquiry made clear. The culture of the NHS played a part too.

It said there was a tendency across NHS management to become pre-occupied with avoiding blame and focusing on reputation management - something that was apparent in the approach over Letby.

And despite attempts over the last 10 years to bring in protections for whistleblowing there was still evidence of a “toxic negativity” that discouraged people working in the NHS to speak out.

Regulation was also found lacking. The Care Quality Commission inspected the Countess of Chester in February 2016 – Letby carried on attacking babies until June of that year. Key information was withheld from inspectors, but the regulator was criticised for not showing enough curiosity to look beyond what they were being told.

What makes this worse is that only a year before, the CQC had been warned by the inquiry into baby deaths at Morecambe Bay NHS Trust that it needed to take a tougher approach.

Nat Wright
Health reporter

We're continuing to bring you lines from the recently published report - as a reminder, you can watch her news conference live at the top of the page.

Lady Justice Thirlwall has made 17 recommendations which include CCTV for all cots and incubators in all neonatal units, restricted access to insulin, obligatory safeguarding training for staff, a harmonised IT system across the NHS and better handling of data.

She says there should be the creation of Suspicion of Deliberate Harm Protocol and guidance; a panel of experts should be set up to be called upon where concerns emerge about an individual and harm to patients.

By 31 March 2027, all hospital trusts must have in place effective mechanisms forboard level monitoring of all deaths of children and babies.

Further checks are needed when managers are being moved to different trustswith a code of conduct for managers (which was published in July 2026) to be amended with suggested wording"I will make the care and safety of patients my first concern and act to protect them from risk."

There should be without-notice Care Quality Commission (CQC) inspections and inspectors should not take things at face value; the CQC should be reviewed once a year at first and then every three years after.

The function of the National Guardian’s Office should be taken over by the Parliamentary and Health Service Ombudsman in England which should be given greater powers to investigate whistleblowers’ concerns.

Lauren Hirst
Reporting from Liverpool

Here is more from the inquiry report.

While the Thirlwall Inquiry did not look at Letby’s guilt, it found:

• Letby ignored management instructions when she disliked them, and shouted at her manager
• Falsified records, while one infant in her care was found covered in their own faeces
• She was repeatedly untruthful in her dealings with friends and colleagues, and
• Had an inappropriate and callous nature noted by patients

We can bring you more from the report now.

• The first three deaths (babies A, C, and D), in June 2015, were not viewed as a cluster, even though this was the annual average number of deaths, concentrated within two weeks
• The fourth death of baby E in August 2015 was unexpected, and therefore reviewed at a serious incident panel meeting attended by the medical director and director of nursing - but it was treated as a formality. "What is surprising is that no connection was made by any of the people involved to the earlier deaths," the report says
• If Dr ZA had not disregarded an insulin test result for baby F in August 2015 then there should have been safeguarding action. The report says this would have prevented the attacks on babies G and H, J, K, L, M and N and the deaths of baby I, O and P
• If safeguarding action had been taken by October 2015 - after the death of baby I - by moving Lucy Letby off the ward, the deaths of babies O and P would have been prevented as would the attacks on babies J, K, L, M and N, the report says
• Dr Jayaram should have reported what he had seen regarding baby K in February 2016
• In May 2016, no-one raised safeguarding at a meeting with executives - if they had done it would have prevented the deaths of babies O and P

We're continuing to bring you key details from the inquiry report, published minutes ago.

Parents of the babies were “kept in the dark for years” over the concerns that their babies may have been deliberately harmed.

Lady Justice Thirlwall found the lack of consideration shown to parents was “reprehensible”.

Hospital executives used the risk of upsetting the parents as a convenient argument to justify not calling the police.

Lady Justice Thirlwall, the inquiry's chair, is speaking now.

We'll be covering her statement here, which you can also watch live at the top of this page.

"It should never have been about nurses against doctors. It was about keeping babies safe," the inquiry chair writes.

The doctors were not given the protection of the Speak Out Safely whistleblowing policy.

Senior managers tried to "manage out" the consultants and spoke of referring them to the General Medical Council.