The long-awaited Thirlwall Inquiry report has concluded there was a “complete failure” to protect babies at the Countess of Chester Hospital, finding profound failures in management, governance and safeguarding and saying some babies could have been saved if action had been taken earlier.
Lady Justice Thirlwall published her final report on 15 September following the independent statutory inquiry into events at the hospital and the response to concerns surrounding former neonatal nurse Lucy Letby.
The report is highly critical of senior management and nursing leadership, finding a prolonged delay in involving police and a fundamental failure to understand that safeguarding action should be taken when a member of staff is suspected of deliberately harming patients.
However, the inquiry did not determine whether Letby's criminal convictions are safe. That issue remains separate from the inquiry and is currently being reviewed by the Criminal Cases Review Commission.
'Complete failure to protect babies'
Lady Justice Thirlwall said the report described dysfunctional management and governance, a gulf between hospital leadership and clinicians, and a failure to understand the fundamentals of safeguarding.
She concluded there had been a “complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital”.
The inquiry found that safeguarding action should have been taken once there was suspicion that a member of staff might be deliberately causing harm. It said certainty of guilt was not required before protective measures were taken.
According to the inquiry, some babies would have been saved and some attacks prevented had action been taken earlier.
Senior managers criticised over response
The report found that senior nurses never accepted that consultants' concerns about Letby were, or might have been, justified and that senior managers took too long to call the police.
It was also critical of successive internal and external reviews commissioned after concerns were raised, saying they failed to address the central question of whether deliberate harm might have been occurring.
The Royal College of Paediatrics and Child Health accepted that the service review it carried out could not address the doctors' concerns and, according to the inquiry, should not have been undertaken for that purpose.
Clinicians who raised concerns were themselves investigated as part of Letby's grievance process. Three consultants were told to apologise to her, while plans were developed — although ultimately abandoned — to return Letby to the neonatal unit.
Parents 'kept in the dark'
The inquiry also strongly criticised the way families were treated.
Parents were not told for years that concerns had been raised that their babies might have been deliberately harmed. The inquiry said parents were not informed about reviews and their consent was not obtained before medical records were shared with external experts and organisations.
Lady Justice Thirlwall said the lack of consideration shown to the parents was “reprehensible”.
17 recommendations for NHS reform
The report makes 17 recommendations intended to strengthen safety in neonatal units and improve the way the NHS responds when deliberate harm by a member of staff is suspected.
Among the recommendations is the installation of baby monitors with livestreaming cameras on cots and incubators in neonatal units, allowing parents to observe their babies remotely and potentially acting as a deterrent to deliberate harm.
The inquiry also recommends CCTV coverage of insulin storage until access can be controlled using biometric systems.
By 31 March 2027, the report says hospital trusts should have effective mechanisms for board-level monitoring of deaths involving babies and children, with clear procedures for escalating concerning trends or patterns.
It also calls for an NHS-wide protocol governing cases where a member of staff is suspected of deliberately harming a patient.
Government promises action
Health and Social Care Secretary Yvette Cooper apologised on behalf of the Government and health service for the failures identified by the inquiry.
The Government has begun urgent work on plans for CCTV and “cot cams” in neonatal settings and says it will also pursue stronger safeguarding, inspections and accountability for NHS managers while considering all 17 recommendations.
Cooper said safeguarding must be at the heart of the NHS and that lessons from the report must result in change.
What the inquiry does — and does not — decide
The publication comes amid continuing public and professional debate about Letby's convictions.
Letby was convicted following two criminal trials of murdering seven babies and attempting to murder seven others. She is serving 15 whole-life orders and has consistently maintained her innocence.
The Thirlwall Inquiry was not a retrial and was not established to determine whether those convictions are safe. Its purpose was to examine events at the Countess of Chester Hospital, the response of staff and management, the experiences of families and the effectiveness of NHS governance, regulation and safeguarding.
Lady Justice Thirlwall has previously stressed that a statutory inquiry cannot determine criminal liability or overturn a jury's verdict.
Convictions remain under separate CCRC review
Questions about the safety of Letby's convictions are being considered separately by the Criminal Cases Review Commission.
The CCRC confirmed in February 2026 that its review of Letby's convictions was underway after receiving a preliminary application in February 2025 and further submissions, expert reports and defence material over the following year.
The Commission has emphasised that it does not decide guilt or innocence. Its role is to determine whether new evidence or argument creates a real possibility that a conviction would not be upheld and should therefore be referred back to the appeal courts.
An application to the CCRC does not itself mean that a conviction is unsafe.
David Davis has questioned the convictions
Among those publicly questioning the case is Conservative MP Sir David Davis, who has repeatedly raised concerns in Parliament about the evidence and investigation that led to Letby's convictions.
In a House of Commons debate in January 2025, Davis said he believed a retrial would clear Letby. In March 2026 he used a further parliamentary debate to challenge aspects of the Cheshire Police investigation.
Those statements represent Davis's assessment of the case and do not alter Letby's legal status. Her convictions remain in force unless and until overturned by a court.
The Government has maintained that it would be inappropriate for ministers to comment on the reliability of the convictions while the independent criminal justice process continues.
Two separate questions
The publication of the Thirlwall report therefore leaves two distinct issues running in parallel.
The inquiry has reached severe conclusions about how the hospital responded to suspicions of deliberate harm and has proposed major changes to NHS safeguarding. Separately, Letby's legal team and others continue to challenge the evidence behind her convictions through the CCRC process.
The inquiry's findings do not resolve that legal debate, and the CCRC review does not invalidate the inquiry's findings about hospital governance and safeguarding.
Lady Justice Thirlwall has urged those discussing the case to remember the continuing impact on the families, saying they should not become “collateral damage” in the public argument over whether Letby is guilty.