Key Findings from Lucy Letby Thirlwall Inquiry
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Figure caption: The key findings and recommendations from the Lucy Letby report
By Lauren Hirst, Judith Moritz, Special correspondent, and Nick Triggle, Health correspondent
Published 15 September 2026
The public inquiry into how serial killer Lucy Letby was able to murder babies at the Countess of Chester Hospital has delivered its findings, describing a "complete failure" to protect infants from harm.
After hearing from more than 130 witnesses and considering 400 statements over six months, the Thirlwall Inquiry report was published earlier at Liverpool Town Hall.
The inquiry began in September 2024, after Letby was convicted of murdering seven babies and attempting to murder seven others - one of whom she attempted to kill twice.
Below are the key findings from Lady Justice Thirlwall's report, which ran to more than 1,100 pages over three volumes.
Hospital 'missed opportunities' to prevent murders
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The first three deaths in June 2015 (babies A, C and D) were not viewed as a cluster of deaths, even though this was the annual number of deaths, concentrated into two weeks.
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The fourth death (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," noted Thirlwall.
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By August of that year, the total of four deaths was the highest since 2008, and was to double by the end of the year.
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If a doctor - named in the report as Dr ZA - had not disregarded the insulin test result for Baby F in August 2015 then there should have been safeguarding action.
Safeguarding Failures
The report found:
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Safeguarding action would have prevented the attacks on babies G, H, J, K, L, M and N and the deaths of Baby I, O and P.
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If safeguarding action had been taken by October 2015 - after the death of Baby I - by moving 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.
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In February 2016, Dr Ravi Jayaram should have reported what he had seen regarding Baby K.
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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.
Systemic Failures at Countess of Chester Hospital
Thirlwall found there was a "complete failure to protect babies on the neonatal unit" at the Countess of Chester Hospital, where Letby, now 36, murdered seven babies and attempted to murder seven others, one of them twice. She described a system of "dysfunctional management and governance."
Hospital Bosses' Conduct
She added that hospital bosses repeatedly failed in their duty of candour with parents, investigators and regulators. Their behaviour was "high-handed, against all safeguarding principles, and foolhardy."
Medical director Ian Harvey "sought to control the narrative," and presented the case as he saw it. He made sure that only documents that supported his case were seen, if necessary writing them himself.
The report also found:
- Director of nursing Alison Kelly, the head of safeguarding, knew she had to act when there was a suspicion that a baby had been harmed, and others might be at risk – but did not.