Lucy Letby inquiry: what have we learnt as it comes to an end?

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Lady Justice Thirlwall has not rehashed the trial — instead she looked at what might have been done to stop the nurse’s killing spree sooner

Constance Kampfner

, Northern Correspondent

Friday January 17 2025, 5.00pm GMT, The Times

Since the autumn, two competing debates have unfolded simultaneously in the public arena, each claiming to try and get to the bottom of what happened at the Countess of Chester Hospital between 2015 and 2016.

Inside Liverpool Town Hall, an orderly succession of witnesses — hospital bosses, NHS leaders and bereaved parents — have sought to answer how and why opportunities were missed to prevent the neonatal nurse Lucy Letby from murdering seven babies and trying to kill seven more.

Lady Justice Thirlwall, who has been conducting the inquiry, which heard its final evidence this week, was critical of that “noise” as she opened proceedings in September. Those casting doubt on the verdict, who were not themselves at the trial, were causing “enormous additional distress to the parents, who have already suffered far too much,” she said.

Letby, 35, who is serving 15 whole-life terms in jail, has failed in two attempts to challenge her convictions.

As Thirlwall emphasised, the inquiry was not about rehashing the case but was about examining what might have been done to stop Letby’s killing spree sooner.

The evidence presented over the past few weeks, much of which was not heard at the criminal trial, has uncovered new details about Letby, and painted a picture of an increasingly tense atmosphere at the Countess of Chester before police were finally called to intervene in May 2017.

Here is some of what we have learnt.

Letby’s ‘odd’ behaviour

Through her 14 days in the witness box during her trial, and under nearly 60 hours of questioning, Letby left many people with more questions than answers about what could have led a popular young nurse to become Britain’s most prolific child killer.

A court sketch of Letby as she was questioned by her barrister Ben Myers at Manchester crown court

ELIZABETH COOK/PA

The inquiry has painted a more complicated picture of a woman considered likeable by some, but “weird” and “cold” by others and even “gossipy” when imparting news of infant deaths.

“You’ll never guess what’s happened,” she is said to have told a colleague after two deaths for which she was later convicted, as if something “exciting” had happened. Another nurse recalled Letby telling her she had “just wanted to get her first death out of the way”.

One bereaved mother described Letby’s behaviour after her baby’s death as having been “very different” to that of the other nurses and, on reflection, “very odd”. “She was just as upset as me,” she said. “She looked like every time she spoke to me she was on the verge of tears, very upset … I thought she was being kind.”

There was a big disclosure early in the inquiry, when it was told that babies’ breathing tubes had been dislodged at an unusual rate during Letby’s student placements at Liverpool Women’s Hospital. An audit showed that such incidents had happened in 40 per cent of the shifts she worked, compared with less than 1 per cent of shifts for other nurses.

Last month, police confirmed Letby had been questioned under caution in prison by detectives investigating deaths and non-fatal collapses at Liverpool Women’s Hospital, and more such incidents at the Countess.

Dr Stephen Brearey, the lead neonatal consultant at the Countess, told the inquiry it was “likely” that Letby had murdered or assaulted more children than are known at present.

A note found in Letby’s house that was shown during her trial — including the phrase “I am evil I did this”

PA

Missed opportunities to alert police

Before June 2015, deaths on the Countess neonatal unit were rare — usually no more than two or three a year. In that month alone, three babies died and a fourth had only narrowly survived a collapse.

Police were not automatically alerted to the spike, the inquiry was told, because paediatricians did not follow protocol for reporting the sudden unexpected death of a child, mistakenly believing that it applied only to deaths outside a hospital.

Consultants did raise concerns about the increase internally, but a meeting with department heads on July 2 concluded that no further investigation was warranted. This was described as a “significant missed opportunity”.

In August 2015, blood tests on Baby F revealed dangerously high insulin levels, suggesting that the baby had been deliberately harmed. The inquiry was told that these results were “not interpreted correctly at the time” and the hospital failed to act on this clear indicator of foul play.

An external thematic review in February 2016 identified some “suboptimal care issues” but there was at that time a “very firm pushback” from senior nurses that suspicions about Letby were “totally wrong”, Dr John Gibbs recalled as he voiced his regret about not going to the police then.

Although Letby had been linked to several incidents, she was removed from the unit only after two triplets died and a baby boy collapsed in June 2016.

At this point, rather than notifying the police, the hospital opted for an external review by the Royal College of Paediatrics and Child Health, a decision described as “completely inadequate” by Rachel Langdale KC, counsel for the inquiry.

Rachel Langdale KC, counsel to the inquiry, arriving at Liverpool Town Hall

EPA

The hospital board did not escalate concerns to Cheshire police until May 2017, nearly two years after suspicions about Letby first arose. This delay was partly due to advice from a non-executive director, who was reported to have told Ian Harvey, then the hospital’s medical director, that police involvement should be avoided until “all other avenues had been exhausted”.

Threats, recriminations and Freemasons

At first, consultants thought Letby was simply unlucky to have been present at so many deaths, but suspicions soon grew and a rift opened between doctors and nurses on the unit.

Eirian Powell, the neonatal ward manager, had described Letby as “one of my best nurses” and “100 per cent innocent”. At the same time, junior doctors started to call her “nurse death”.

Some sympathetic staff even organised a tea party in 2017 to celebrate Letby’s expected return to the neonatal unit.

Seven consultants were told to sign a joint letter of apology to Letby after Tony Chambers, the hospital’s chief executive, told them they had upset her by linking her to the spike in fatalities. Chambers has denied that he sought to “ruin the careers” of medics after they brought their concerns to his attention.

Executives have denied the existence of a “culture of fear” at the hospital, but accepted that trust between clinicians and senior leaders had “broken down”.

PETER BYRNE/PA WIRE

The inquiry was also told of “rumours and hearsay” about Freemason connections of a “number of high-ranking people in the hospital and elsewhere”. A judge who was asked to give legal advice to hospital bosses denied that he had been given the role because he was a Freemason — the Countess of Chester’s former director of corporate and legal services, Stephen Cross, was also a member of the organisation.

Brearey said that people at the hospital had had the impression there might be “deals going on behind the scenes”.

Letby’s parents

Susan and John Letby have stood firmly by their daughter, and rented a flat in Manchester for the duration of her ten-month trial. They are reported to have made regular trips to visit her in prison since.

Susan and John Letby attended her trial

PAUL ELLIS/AFP/GETTY IMAGES

The inquiry was told that their defence of her had extended to calling for the “instant dismissal” of two consultants who had raised concerns that she was deliberately harming babies.

Chambers said that Mr Letby had “made threats” in an “angry” meeting after his daughter’s grievance about being removed from the neonatal unit was upheld. He said it had seemed that Mr Letby was “pulling the strings”, adding: “He was threatening guns to my head.”

Chambers denied having been “manipulated” by the Letbys, but accepted that he told the nurse “we’ve got your back”, which he said in hindsight had been “clumsy language”.

Bereaved families’ demands

Accountability for senior management emerged as a central demand of the bereaved parents, who have accused hospital leaders of prioritising reputations over safety.

Their emotionally charged testimony highlighted years of having concerns dismissed and being kept in the dark. Harvey, the former medical director, came in for the strongest criticism.

“Babies died because someone in an office being paid hundreds of thousands of pounds didn’t want the hospital to look bad,” Baby I’s mother told the inquiry.

Watch: the parents of Baby L and Baby M speak after the verdicts in Letby’s trial

The families have called for a legally enforceable duty of candour to ensure greater transparency, as well as a regulatory body — similar to those for doctors and nurses — to improve the accountability of NHS managers.

A statutory duty of candour to patients and families from health and social care providers in England was brought into law in 2014 and is under review by the Department of Health and Social Care. The inquiry was told that it was too often treated as a “bureaucratic process” and a “defence mechanism” rather than as a genuine effort to involve families.

Other suggestions for reforms included psychological evaluations for staff and stronger whistleblower protections, as well as CCTV in neonatal units, a measure several parents believed might have deterred Letby or at least provided critical evidence sooner. Baby D’s mother said: “Every parent that can’t be at the hospital wants to know what is happening to their babies.”

The Thirlwall inquiry will give its recommendations in late 2025.

Lady Justice Thirlwall, chairwoman of the inquiry, at Liverpool Town Hall

PETER BYRNE/PA