Thirlwall Inquiry Finds Complete Failure To Protect Babies At Countess Of Chester Hospital

A public inquiry chaired by Lady Justice Kathryn Thirlwall concluded that there was a “complete failure” to protect babies on the neonatal unit at the Countess of Chester Hospital, and said some deaths could have been avoided if safeguarding action had been taken earlier.

Thirlwall’s report criticised senior staff for not acting sooner, blaming “dysfunctional management and governance” and a “basic lack of understanding of safeguarding” at the hospital in northern England.

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The inquiry did not address whether Lucy Letby was guilty or innocent, but it said “Once there was suspicion that Letby may be causing harm deliberately, safeguarding steps should have been taken,” and that “Suspicion is enough.”

Reuters reported that the chair of the inquiry said Letby was able to murder seven babies because of that “complete failure” to protect infants, and that some deaths could have been prevented.

In Liverpool, England, the report was delivered on Sept 15, with Letby’s lawyer Mark McDonald saying in a statement that the inquiry “has proceeded on the wrong premise” and “inevitably affected the report as a whole.”

Thirlwall told the inquiry that safeguarding action was required when a member of staff was suspected of causing deliberate harm, saying, “No one seems to have thought that safeguarding action is required when a member of staff is suspected of causing deliberate harm.”

In response to the report, Health Secretary Yvette Cooper said she was “profoundly sorry” for the failures set out in the report, and promised a government response later.

BBC

The Criminal Cases Review Commission (CCRC) is examining whether to refer Letby’s case back to the Court of Appeal, and BBC reported that Dame Vera Baird said, “We will be looking at the report with interest to assess whether it has any bearing on our review of the case.”B

Letby’s lawyer Mark McDonald argued that the inquiry’s premise was wrong, while the BBC said the report “won't change the narrative about Letby's guilt or innocence because it didn't examine that subject at all.”B

The Guardian reported that Thirlwall said the inquiry found “a gulf between hospital leadership and clinicians” and “failure to understand the fundamentals of safeguarding,” and that the judge said parents were “kept in the dark” for years.

Thirlwall made recommendations aimed at preventing future harm, including fitting cots and incubators with cameras and stronger insulin storage safeguards, and said NHS England should “set out a roadmap” for implementation by March 31 next year.

“set out a roadmap”

LBC

The Guardian said the report recommended installing 24-hour cameras on every cot in a neonatal unit and beefed-up oversight from the Care Quality Commission, while also warning that she was not reassured ministers would act after the abolition of NHS England.

The inquiry also described how relationships between consultants raising concerns and executives “disintegrated,” and said there was a “prolonged delay” in calling the police after suspicions emerged.

BBC reported that the inquiry was tasked with examining how Letby was able to commit her crimes at the Countess of Chester Hospital in 2015-2016 and whether managers should have responded differently when suspicions were raised.B

For families, the inquiry chair emphasised that “The families must not be collateral damage in the public argument about whether or not Letby is guilty,” while the Guardian reported that families said the report painted a “damning picture” of what happens when patient safety concerns are not acted on.