Lucy Letby’s alarming behaviour & screaming match with boss revealed as inquiry says baby deaths could have been avoided

AN INQUIRY into how Lucy Letby was able to repeatedly kill and harm babies on a hospital neonatal unit has blamed a profound failure of management, governance and safeguarding. Lady Justice Kathryn Thirlwall’s £18million probe, published today, has found deaths could have been prevented if “action” had been taken earlier – and has heaped fresh scathing on Letby herself, including detailing her alarming behaviour. Lucy Letby was convicted of the murder of seven babies and the attempted murder of seven more Credit: PA The deaths occurred between 2015 and 2016 Credit: Getty She said the inability for concerns over Letby’s seven murders and seven attempted murders to be escalated was fuelled by opposing tribalism between doctors and nurses at Countess of Chester Hospital. The Inquiry findings suggest hospital bosses should have been clear with medics called in to investigate unexplained deaths when they suspected deliberate harm – and among its recommendations are CCTV cameras on every cot and incubator. Sign up for The Sun newsletter Thank you! It alarmingly notes, Countess of Chester’s safeguarding policy did not even mention the possibility of malicious actions and know how to manage concerns. Despite growing claims from experts that Letby’s convictions are actually unsafe and she may have been the victim of a miscarriage of justice, Lady Justice Thirlwall has added to the narrative of her guilt. The Thirlwall Inquiry finds… There was “a complete failure to protect babies” on the neonatal ward Deaths could’ve been prevented if “action” was taken earlier Failure to report suspicions were fuelled by a “tribalism” between doctors and nurses Hospital’s safeguarding policy did not mention the possibility of malicious actions and how to manage concerns Letby was “repeatedly untruthful”, “ignored” bosses and acted “inappropriate and callous” with patients; had shouting match with boss The NHS as a whole must follow, and adopt a suspicion of deliberate harm protocol so that managers can no longer refuse to investigate when concerns are raised Among recommendations is CCTV to protect babies, including a camera on every cot and incubator The report says the NHS as a whole must follow, and adopt a suspicion of deliberate harm protocol so that managers can no longer refuse to investigate when concerns are raised. It also focuses on the extensive trail-covering it claims Letby deployed to hide her crimes, as emerged during her 2023 murder trial, noting in a section about her deceit the nurse “ignored management instructions when she disliked them and shouted at her manager”. Most read in The Sun Lady Justice Thirlwall adds Letby also “falsified medical records” and one baby in her care was found “covered in her own faeces”. She said the nurse was “repeatedly untruthful in her dealings with friends and colleagues”, and her “inappropriate and callous behaviour was noted by patients”. Chair of the inquiry Lady Justice Thirlwall arrives at Liverpool Town Hall Credit: PA Letby pictured at the Countess of Chester Hospital in 2012 Credit: MEN Media Referring to “tribalism” on the ward, she goes on to say: “It should never have been about nurses against doctors. It was about keeping babies safe. “Had that governed the approach of the managers, they would and should have sought to work with the doctors, not against them. “Characterising this as nurses versus doctors distracted from the real issue: that steps needed to be taken to protect the babies.” It continues: “At the heart of this deterioration in relationships was a well-known cultural phenomenon: sometimes referred to as tribalism it is unthinkingly loyalty to one’s team or profession. “The senior nurses demonstrated unquestioning loyalty to Letby throughout the events with which I am concerned.” The Inquiry also concluded that senior staff who initially offered Letby legitimate professional support became too personally close to her. Lady Justice Thirlwall said: “There were good reasons to support Letby, and the hospital was right to do so, but every person who supported her stepped very quickly from professional support to personal friendship. “They were all relatively senior people. They should have maintained an appropriate professional distance and not become involved.” Lawyer Mark McDonald is leading Letby’s current appeal Credit: AP There’s a growing fear that Letby was the victim of a miscarriage of justice Credit: SWNS The findings say hospital executives used the prospect of upsetting parents as a “convenient argument” for not calling police, while describing the actual communication with families as “dreadful”. The Inquiry was launched in 2023 in the wake of Letby’s multiple convictions for murder and attempted murder of infants. One of the country’s most senior judges, Lady Justice Thirlwall, heard evidence at Liverpool Town Hall from numerous witnesses between September 2024 and February 2025, including from the parents of Letby’s victims. The inquiry’s key objectives were to seek answers for the victims’ families and ensure lessons are learned – some 25 years after another nurse, Beverley Allitt, committed similar crimes on a children’s ward in Grantham, Lincolnshire. Delivering her report today, Lady Justice Kathryn Thirlwall said: “My report describes dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals of safeguarding. “There was a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital. “This was because no one seems to have understood that safeguarding action is required when a member of staff is suspected of causing deliberate harm and does not require colleagues to be sure of guilt.” The report finds it is clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier. Lady Justice Thirlwall noted that an inquiry had also taken place into events surrounding Allitt’s killing spree and said it was “utterly unacceptable” it had happened again within the NHS. Her investigation did not examine Letby’s convictions or motives but instead focused on the conduct of those working at the Countess of Chester, including the board, managers, doctors and nurses from when Letby started her employment in 2012. The charges Letby was convicted on in full Child A, allegation of murder. The Crown said Letby injected air intravenously into the bloodstream of the baby boy. COUNT 1 GUILTY. Child B, allegation of attempted murder. The Crown said Letby attempted to murder the baby girl, the twin sister of Child A, by injecting air into her bloodstream. COUNT 2 GUILTY. Child C, allegation of murder. Prosecutors said Letby forced air down a feeding tube and into the stomach of the baby boy. COUNT 3 GUILTY. Child D, allegation of murder. The Crown said air was injected intravenously into the baby girl. COUNT 4 GUILTY. Child E, allegation of murder. The Crown said Letby murdered the twin baby boy with an injection of air into the bloodstream and also deliberately caused bleeding to the infant. COUNT 5 GUILTY. Child F, allegation of attempted murder. Letby was said by prosecutors to have poisoned the twin brother of Child E with insulin. COUNT 6 GUILTY. Child G, three allegations of attempted murder. The Crown said Letby targeted the baby girl by overfeeding her with milk and pushing air down her feeding tube. COUNT 7 GUILTY, COUNT 8 GUILTY, COUNT 9 NOT GUILTY. Child H, two allegations of attempted murder. Prosecutors said Letby sabotaged the care of the baby girl in some way which led to two profound oxygen desaturations. COUNT 10 NOT GUILTY, COUNT 11 JURY COULD NOT REACH VERDICT. Child I, allegation of murder. The prosecution said Letby killed the baby girl at the fourth attempt and had given her air and overfed her with milk. COUNT 12 GUILTY. Child J, allegation of attempted murder. No specific form of harm was identified by the prosecution but they said Letby did something to cause the collapse of the baby girl. COUNT 13 JURY COULD NOT REACH VERDICT. Child K, allegation of attempted murder. The prosecution said Letby compromised the baby girl as she deliberately dislodged a breathing tube. COUNT 14 JURY COULD NOT REACH VERDICT. Child L, allegation of attempted murder. The Crown said the nurse poisoned the twin baby boy with insulin. COUNT 15 GUILTY. Child M, allegation of attempted murder. Prosecutors said Letby injected air into the bloodstream of Child L’s twin brother. COUNT 16 GUILTY. Child N, three allegations of attempted murder. The Crown said Letby inflicted trauma in the baby boy’s throat and also injected him with air in the bloodstream. COUNT 17 GUILTY, COUNT 18 JURY COULD NOT REACH VERDICT, COUNT 19 JURY COULD NOT REACH VERDICT. Child O, allegation of murder. Prosecutors say Letby attacked the triplet boy by injecting him with air, overfeeding him with milk and inflicting trauma to his liver with “severe force”. COUNT 20 GUILTY. Child P, allegation of murder. Prosecutors said the nurse targeted the triplet brother of Child O by overfeeding him with milk, injecting air and dislodging his breathing tube. COUNT 21 GUILTY. Child Q, allegation of attempted murder. The Crown said Letby injected the baby boy with liquid, and possibly air, down his feeding tube. COUNT 22 JURY COULD NOT REACH VERDICT. In one of the Inquiry’s most far-reaching conclusions, Lady Justice Thirlwall backs CCTV to protect babies and says every neonatal cot and incubator should have its own camera. She said: “From the outset of the Inquiry, Core Participants and witnesses were asked for their view on whether the Inquiry should make recommendations about CCTV monitoring of neonatal units… “The parents were firmly of the view that CCTV would protect babies on the neonatal unit. I agree. Parents of very young babies will find this reassuring. It will also deter those rare people who seek to harm babies. “I am not persuaded that the cost, training and ‘workload’ implications outweigh those benefits, if those implications are of any real weight at all. “I am sure that all cots and incubators in all neonatal units should be fitted with in-cot cameras with live streaming video, so that parents may observe the baby remotely at any time. “The modest funding required for this should be centrally managed and ring-fenced.” It comes after Letby’s lawyer Mark McDonald says the £18million inquiry has been an error for not being allowed to examine questions over her conviction. He claimed the findings could end up redundant if his application to the Criminal Cases Review Commission leads to Letby’s bid for freedom returning to the Court of Appeal. Letby supporters outside The Royal Courts of Justice Credit: Alamy Police bodycam footage shows Lucy Letby being arrested at home in Chester in July 2018 Credit: AFP Mr McDonald said yesterday: “The whole inquiry was based on the wrong premise that Lucy Letby is guilty. “This error will lead to an unreliable report and more importantly recommendations that may soon be redundant. “The Government needs to pause and not waste any further money until the Court of Appeal has had chance to see the substantial international expert evidence which definitely proves Lucy Letby is innocent.” The Thirlwall report finds that senior nurses never accepted that the consultants’ concerns were – or might be – justified, and that there was a prolonged delay by senior managers in calling the police. It is critical of successive internal and external reviews commissioned by hospital leadership after concerns were raised about Letby. It says reviews did not address whether deliberate harm was being caused or not – and when concerns were raised, clinicians were themselves made the subject of investigation within Letby’s own grievance process. Three consultants were even told to apologise to Letby, and plans were formulated, although later abandoned, to bring the nurse back onto the neonatal ward. The report also reflects the anger some parents feel at the way they were treated, believing they were kept in the dark about what was happening and about concerns that their babies may have been deliberately harmed. Their consent was also not obtained before sharing their babies’ medical records with external experts and other organisations, and they were not informed about reviews. It also reflects their anger at only learning the collapses and deaths may have been the result of the actions of a nurse until 2018. Many parents took the view that protecting the reputation of the hospital was more important to senior managers than keeping them informed about what was happening. Letby, 36, was moved from the neonatal unit to administrative duties in July 2016 after consultants expressed concerns about her to the hospital’s executive team. Hospital bosses opted to carry out a number of reviews into the increased mortality in 2015 and 2016, and did not invite Cheshire Constabulary to investigate until May 2017, as Letby remained on site until her arrest more than a year later. The inquiry examined whether suspicions should have been raised earlier and whether the police and other external bodies should have been informed sooner. It looked at the response to concerns about Letby and whether the culture, management and governance structures and processes of the hospital trust, and the wider NHS, contributed to the failure to protect babies from Letby. The inquiry also heard evidence about whether the accountability of senior managers should be strengthened. Sir Robert Francis, who chaired the inquiry into chronic care failings at Mid Staffordshire NHS Foundation Trust, told Lady Justice Thirlwall there was no regulator “with teeth” to impose sanctions on poorly performing non-clinical directors. Letby, from Hereford, who maintains her innocence, is serving 15 whole-life terms for the murders of seven babies and attempted murders of seven others by various means between June 2015 and June 2016. She was twice denied permission to appeal against her convictions in 2024. The Criminal Cases Review Commission, which investigates potential miscarriages of justice, is considering evidence presented on her behalf by an international panel of medics who claim poor medical care and natural causes were the reasons for the babies collapsing. A number of doctors, scientists and statisticians have publicly challenged the way the evidence was presented to jurors at her trial. Last year, Lady Justice Thirlwall rejected separate applications from Letby and the Countess of Chester’s former senior management team to pause her inquiry pending the outcome of Letby’s bid to clear her name. Solicitors representing Letby wrote to her with concerns that the final report would “not only be redundant but likely unreliable”, and if the convictions were overturned, would be “based on the wrong premise”. Lawyers for the management team in 2015 and 2016 said there was a “real possibility” the convictions would be overturned. However, legal teams for the families of Letby’s victims said it was yet another “cynical attempt” by the former nurse to control the narrative and that the executives wanted to avoid criticism. They added there was “nothing remarkable or new” about the evidence presented by the international panel of medics. Richard Scorer, head of abuse law and public inquiries at Slater and Gordon and lawyer for three of the families of Letby’s victims, told Times Radio on Tuesday that the hospital system had “very badly let down” parents and families. “In addition to that, there’s the whole issue of the duty of candour, and the failure of the hospital to be candid with parents about what was really going on, which went on over a very long period of months and years,” he said. Mr Scorer added he felt it was “inevitable” there would be culpability attributed to both individuals involved in the hospital’s response and the hospital as an institution. “What we’ve got to ensure is that these kinds of mistakes are not repeated in future cases if they should happen,” he said. “That means ensuring that there are mandatory procedures that have to be followed in this kind of situation and that there is a much-strengthened duty of candour within the NHS.” A court order prohibits reporting of the identities of the surviving and dead children involved in the case. Investigations by Cheshire Constabulary into potential offences of corporate manslaughter and gross negligence manslaughter remain ongoing. Inquests into the deaths of babies who Letby was convicted of murdering are to take place in May 2027.